SLEEP STUDY - PATIENT QUESTIONNAIRE
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- Kimberly Casey
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1 NOTE: You cannot fill out this form on Mozilla Firefox, please try another browser. You have two options for completing a questionnaire: - Enter the information on the fillable PDF and click Print at the end of the document - Print the questionnaire and fill it out by hand The Sleep Log and Authorization Signature must be completed by hand. Please bring the completed questionnaire(s) to the office or sleep lab. SLEEP STUDY - PATIENT QUESTIONNAIRE DATE: Who is the Physician ordering the Sleep Study? Who is the primary care Physician? Do you want this report sent to another Physician? PERSONAL INFORMATION Patient s Name: First: Date of Birth: Middle Initial: Last: Sex: Male Age Home Address: Home Phone #: Cell Phone #: Work Phone #: Place of Employment: Occupation: Weight: lbs. Height: EMERGENCY CONTACT PERSON Name: Relationship: Home Phone #: Cell Phone #: INSURANCE INFORMATION Primary Insurance: Secondary Insurance: (Complete only if you are not the Insurance Policy Holder) Policy Holder Name: First: Middle Initial: Last: Relationship: Policy Holder s Date of Birth: Policy Holder s Address: City: State: ZIP Code: 1 ft in Female
2 AUTHORIZATION I authorize the release of any medical information necessary to process my insurance claim, and authorize payment of medical benefits to the facility and providers for services rendered. I am aware that payment of insurance copay/deductible is patient responsibility. If necessary, I also authorize release of medical information to durable medical equipment providers and referring/primary care providers involved in my care. I authorize the use of audio and video monitoring as part of my sleep study. I understand that the copay / deductible is my responsibility. I am also aware that the Sound asleep Sleep Diagnostic Lab facility is owned and operated by Narendra R.Kumar,M.D,P.C Date: Sign: 1. On work days: I try to go to sleep at (AM/PM): I wake up at (AM/PM): I get out of bed at (AM/PM): I wake up at (AM/PM): I get out of bed at (AM/PM): 2. When I am not working: I try to go to sleep at (AM/PM): Do you take naps? If yes, how many naps per week? Average duration of naps? Do you or have you been told that you.... snore loudly and disruptively so that family members complain? 5. hold your breath or stop breathing during sleep? 6. have difficulty sleeping on your back or trouble breathing while lying flat? 7. a dry throat or excessive thirst? 8. having achy or restless legs? 9. wake up gasping and/or choking? 10. have an itching or crawling sensation in your legs? 11. unable to fall asleep due to restless legs? 12. take naps? 1. at times, have to struggle to stay awake? 1. have a problem with your performance at work due to sleepiness or fatigue? 2
3 STOP-BANG Questionnaire Do you snore Loudly? Do you often feel tired, fatigued or sleepy? Have you been observed to stop breathing during sleep? Do you have high blood pressure? BMI - (Weight/Height Index) over 5? BMI Calculator Are you over 50 years of age? Is your collar size over 16 inches for male, or 1 inches for female? Are you a male patient?
4 EPWORTH SLEEPINESS SCALE In contrast to just feeling tired, how likely are you to doze off or fall asleep in the following situations? Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation. 0 = WOULD NEVER DOZE 1 = SLIGHT CHANCE OF DOZING 2 = MODERATE CHANCE OF DOZING = HIGH CHANCE OF DOZING SITUATION CHANCE OF DOZING Sitting and Reading Watching TV Sitting inactive in a public place (i.e., in a theatre) As a car passenger for an hour without a break Lying down to rest in the afternoon Sitting and talking to someone Sitting quietly after lunch (without alcohol) In a car, while stopping for a few minutes in traffic Total Please list any medications you are currently taking, including any medications that you have taken in the past months. Please be sure to specify the dosage and the time of day you take them. (**unless otherwise instructed by the physician that ordered your sleep study, continue to take all medications as usual.) MEDICATION LIST Are you allergic to any medications? If yes, please list: Have you ever taken a prescription medication to help you fall or stay asleep? If yes, what and when?
5 Do you or have you been told that you 15. wake up with morning headaches? 16. have restless sleep? 17. walk in your sleep? 18. talk in your sleep? 19. grind your teeth? 20. wet the bed (as an adult)? 21. disturb the sleep of your bed partner? 22. have disturbed sleep due to bed partner? 2. awaken from sleep screaming or violent? 2. have heartburn or gas during the night? 25. wake up with a burning sensation in your throat? 26. sweat excessively during sleep? 27. eat during the night without being aware you do so? 28. have a persistent cough at night? 29. have frequent need to urinate while sleeping (more than twice)? 0. have nasal congestion? How often do you 1. take naps? 2. feel refreshed after you nap?. experience dream-like images while falling asleep?. have episodes of muscular weakness when laughing, angry, or any extreme emotional situation? 5. ever feel paralyzed when waking up? 6. excessively sleepy during normal wake hours? 7. feel alert and Energetic the ENTIRE day? 8. awaken from noise, cold, pain, or other stimulus? 9. How many unintentional naps do you take in a normal day? 0. How many times have you fallen asleep at work? 1. How many times have you had an accident at work due to sleepiness? 2. How many times have you had an auto accident caused by sleepiness?. How many times have you had a near auto accident (driving off the shoulder of the road, etc.) due to sleepiness?. How long does it take you to feel alert in the morning? 5. How many times during the night do you wake up?
6 6. How many times do you get out of bed during a typical night? 7. Have you previously been tested for a sleep disorder? If yes, please list: When Are you on treatment for this condition? Where A. Diabetes: B. High Blood Pressure: C. Heart Disease (heart failure / atrial fibrillation / heart attack): D. Do you have a pacemaker / defibrillator? E. COPD / Emphysema / Asthma? F. Do you use oxygen at home (Day / Night): G. Heart burn / Reflux / Hiatal hernia): H. Chronic Back / Neck or Hip pain? I. Migraines or chronic headaches? J. Depression K. Insomnia L. Neurological condition (Stroke / MS / Parkinson s) M. Muscular skeletal disorders (Fibromyalgia / Muscle weakness) N. Rheumatism / Rheumatoid arthritis or Osteoarthritis: O. Sleep related eating disorders? 8. Have you ever used CPAP/BiPAP? If yes, since which year? 9. Are you currently using CPAP/BiPAP? If yes, list how many hours per night. 50. Have you had your tonsils or adenoids removed or palatoplasty (surgical procedure) for sleep apnea? If yes, list what procedure and when. 51. Are you or have you ever been treated for the following? Kidney Failure: Additional Info: 52. Which shift are you currently working? First 5 Second Third
7 5. Do you drink alcohol in excess? 5. Do you smoke? If yes, list how much per day: If you used to smoke but no longer do, please list when you quit and how much you smoked prior to quitting. 55. How much of the following fluids do you drink during a 2 hour period (please designate in ounces): Caffeinated coffee or tea Water or juice Caffeinated pop Alcohol Other 56. What problems are you currently having with your sleep? (please describe) 57. Do these problems seem to interfere with your daily life? 58. Do you feel that you get enough sleep? 59. Do you wake up after a night s sleep and feel that you are not rested or refreshed? For the following statements, circle the number that best describes your answer: 0= Never 1= Rarely 2= Sometimes = Frequently = 60. You feel fatigued (exhausted) even when you are NOT sleepy 61. You have trouble falling asleep at night 62. You have trouble staying asleep once you fall asleep 6. watch television 6. eat snacks in bed 65. read a book 66. listen to the radio 67. do homework or work brought home from your job 68. Other When you go to bed you: 6
8 At the beginning of the night when you are attempting to fall asleep, how often do you: 69. have thoughts racing through your mind that tend to keep you awake? 70. feel sad and/or depressed? 71. feel anxious and/or tense? 72. feel afraid that you will not be able to fall asleep? 7. worry about being rested and alert the following day? 7. try to make yourself fall asleep? SLEEP LOG Complete this sleep log as instructed using the directions provided below. Complete the log in the morning and in the evening. Write additional comments on the back 1. BLACKEN in the times when you are sleeping. 2. DOWN ARROW indicating the time you are in bed to sleep.. UP ARROW indicating when you got out of bed. In the sample sleep log, this person woke up at 8am, but did not get out of bed until 9am. Then he/she laid in bed for an afternoon nap at noon and fell asleep within minutes. When he/she woke up at 2pm, he/she immediately got out of bed. In the evening, this person went to bed at 9pm, but did not fall asleep until 10pm. During the night, this person was awake from am to 5am, did not get out of bed. Again, he/she slept until 8am and got out of bed at 9am. **Please fill out this sleep study-recording your sleep routine for the week prior to your sleep study** Please bring this completed form (with signature & sleep log) and also your insurance card when you come to the sleep lab. Print 7
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