2665 North Decatur Rd, Suite 435 Decatur, GA Phone: Fax: Name: Date: Gender: M F SS#
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1 North Decatur Rd, Suite 435 Decatur, GA Phone: Fax: Name: Date: Gender: M F SS# Marital Status: M S D W DOB: addr: Emergency Contact: My MAIN sleep problem has bothered me: longer than 2 years several months to 12 months 1 to2 years within the last 3 months within 1 month If previously diagnosed with a sleep disorder please indicate and prescribed treatment: Previously diagnosed with: Sleep apnea RLS/Periodic Limb Movements Narcolepsy Insomnia When Where Treatment: SLEEP SYMPTOMS: Please check the following symptoms that APPLY Symptom Awaken with a dry mouth Morning headaches My mind races with many thoughts when I try to fall asleep Snoring Fatigue Anxiety Memory impairment Inability to concentrate Irritability Depression Suicidal thoughts Pain which delays or prevents my sleep Pain which awakens me from sleep Vivid or lifelike visions (people in the room, etc) as you fall asleep or awaken Awaken gasping for air Sudden weakness or feel your body go limp when you are angry or excited Inability to move as you are trying to go to sleep or wake up Unpleasant leg sensation causing irresistible urge to move legs or arms Creeping or crawling sensation in your legs before falling asleep Legs or arms jerking during sleep
2 2 Sleep talking Sleep walking Nightmares Fall out of bed Heartburn, sour belches, regurgitation, or indigestion which disrupts sleep Bed wetting Frequent urination disrupting sleep Teeth grinding Wheezing or cough disrupting sleep Sinus trouble, nasal congestion or post-nasal drip interfering with sleep Shortness of breath disrupting sleep MEDICAL HISTORY Please check if you have had any of the following: Hepatitis High Cholesterol Diabetes High blood pressure Intestinal Disease Thyroid Condition Irregular heartbeat Reflux Venereal disease Heart Attack Ulcer HIV Heart Failure Head Injury Blood clot TB Parkinson s disease Anemia Chronic Bronchitis Glaucoma Arthritis Pneumonia Kidney/Bladder Gallbladder problems Sarcoidosis Stroke Fibromyalgia Asthma/Emphysema Rheumatic Fever Cancer Sinusitis Other: FAMILY HISTORY: (Please check all that apply) Apnea Snoring Narcolepsy Diabetes Stroke Cancer Heart Disease Deceased Age? Mother Father Sister(s) Brother(s) Grandparent(s) BMI What do you weigh now? What is your height? What was your weight? 1 year ago 5 years ago Neck size? Current 1 year ago SOCIAL HISTORY Do you smoke now? Y/N Previously smoke? Y/N How much per day? Do you drink alcohol? Y/N How much? per day How much caffeinated coffee, tea or cola do you drink daily? I am currently working: Y/N Retired Disabled
3 3 SLEEP HABITS Please answer the following questions as accurately as possible. Indicate AM and PM. Activity Time you enter bed and turn off the lights I usually fall asleep in (minutes, hours) How often do you awaken each night? Number of times you have difficulty returning to sleep The total time I spend awake in bed What time do you usually get out of bed from sleep? How many daily hours sleep do you usually get? Begin work time/end work time Your bedtime schedule Indicate total length of naps daily If you do rotating shift work, or have other work schedule changes and need more space to describe: List all Medications: (or provide typed sheet) NAME DOSAGE FREQUENCY Allergies?:
4 4 PLEASE CHECK ANY SYMPTOMS PRESENT IN LAST TWO WEEKS Constitutional Gastrointestinal Neurological Change in weight Nausea / vomiting Freq. / severe Headaches Fever / chills / night sweats Vomiting blood Numbness or tingling Trouble Swallowing Incoordination / Respiratory recent falling Short of breath Indegestion or Heartburn Weakness in legs and arms Coughing / Asthma / wheezing Coughing up blood Abdominal Pain/Swelling Bloody or Dark Stools Diarrhea/Constipation Skin Itching / rash / skin lesions Changes in a mole Breast Pain /Lump Cardiac Genitourinary Endocrine Chest pain / Problems voiding / Heat/Cold Intolerance discomfort urinating Short of breath when reclining Musculoskeletal Excessive Thirst Urination Fast pulse / irregular heart / Arthritis / Joint Swelling /Aches Palpitations Hematological Wake up short of breath Black out spells / fainting / dizziness Leg / ankle swelling Eyes, Ears, Nose & Throat Hearing difficulty / ringing in ears Sinus / nasal / cold symptoms Back / rib cage / chest wall pain Joint Stiffness History of blood clot Enlarged lymph nodes Paralysis/Limb Weakness Excessive bruising / bleeding Sore throat / hoarseness / throat pain Changes in vision / double vision Psychiatric Unusual anxiety / depression Drug / alcohol addiction
5 5 TAKE THE SLEEPINESS TEST EPWORTH SLEEPINESS SCALE How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. 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 2= moderate chance of dozing 1= slight chance of dozing 3= high chance of dozing Situation Chance of dozing Sitting and reading Watching TV Sitting, inactive, in a public place (e.g. a theatre or a meeting) As a passenger in a car for an hour without a break Lying down to rest in the afternoon when circumstances permit Sitting and talking with someone Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in traffic TOTAL
6 6 Sleep Diary Please complete a diary of your typical sleep pattern for the two (2) days before to your study. Each column represents one day. Indicate in each column the requested information. Day One Day Two Date Lights Out Time it took to fall asleep Number of awakenings Total time awake Lights On Nap Time During the Day Total Time Asleep Comments:
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