SLEEP QUESTIONNAIRE THE EPWORTH SLEEPINESS SCALE

Transcription

1 SLEEP QUESTIONNAIRE Patient Name: Height: Weight: Date : My Main Sleep Complaint(s) : Trouble sleeping at night.. yes no Falling asleep.. yes no Staying asleep.. yes no Snoring. yes no Stop breathing yes no If other, please explain: Sleep Habits Typical bedtime: Time in bed: Typical wake up time: Does your sleep problem effect your work.. yes no if yes, occupation: Do you take naps: yes no Number of naps per day: For how long: I frequently travel across 2 or more time zones.. yes no I drink alcohol prior to bedtime.. yes no I smoke prior to bedtime or when I awaken during the night.... yes no I eat if I awaken during the night... yes no I typically awaken to urinate during sleep yes no I awaken frequently during the night yes no Thoughts start racing through my mind when I try to fall asleep. yes no I awaken early in the morning, still tired but unable to return to sleep yes no I have nightmares as an adult yes no I experience a creeping-crawling or tingling sensation in my legs when I try to fall asleep. yes no Daytime Sleepiness I have a tendency to fall asleep during the day.. yes no I have fallen asleep while driving.. yes no I have experience sudden muscle weakness in response to emotions such as laughter, anger or surprise yes no I drink caffeinated beverages during the day yes no cups / bottles / cans per day THE 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. Use the following scale to choose the most appropriate number for each situation. 0 = Would never dose 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozing SITUATION CHANCE OF DOZING (CIRCLE APPROPRIATE #) Sitting and reading Watching TV Sitting inactive in a public place (e.g. a theater or a meeting) Sitting in a car as a passenger for a continuous hour Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after a lunch without alcohol Sitting in a car stopped in traffic for a few minutes Score: 0-10 Normal range Borderline Sleepy Total: Please list any medications are taking including dosage:

2 PRE-SLEEP BEDTIME QUESTIONNAIRE Name: SSN: Date: 1. Do you wear dentures? Yes No If yes, do you wear them while you sleep? Yes No 2. Do you wear contact lenses? Yes No If yes, do you wear them while you sleep? Yes No 3. Did you take any naps today? Yes No If yes, at what time? how long was your nap? 4a. What time did you go to sleep last night? b. What time do you usually go to sleep? 5a. What time did you wake up today? b. What time do you usually wake up? 6. How many times did you wake up last night? 7. Do you feel you got enough sleep last night? Yes No 8. Have you had any alcoholic beverages today? Yes No If yes, at what time? what type? how much? 9. Have you taken any medications or pills today? Yes No If yes, please list below: (please include non-prescribed medications and over the counter items) Medication Dosage Time taken Purpose 10. Have you had any caffeinated beverages after 12 noon today? Yes No (Colas, coffee, tea, cocoa, etc.) If yes, what type? how much? what time? 11. Have you used any tobacco products today? Yes No If yes, what type? how much? what time? 12. Did you get your normal amount of exercise today? Yes No If no, how was today different from usual? 13. Did anything out of the ordinary happen to you today? Yes No If yes, describe 14. Do you have any physical discomfort/pain at the present time? Yes No If yes, describe Additional comments:

3 NO SMOKING & VIDEO RECORDING POLICIES The Niolopua Sleep Wellness Center smoking policy is as follows: THERE IS TO BE NO SMOKING ANYWHERE IN THIS BUILDING. You may smoke outside in the designated smoking areas before you begin your setup if you inform your technologist BEFOREHAND and if there is time. Once setup begins you will not be permitted to go outside until the study has ended. The fire sensors in the building are very sensitive. SMOKING WILL SET OFF THE FIRE ALARMS. The smoker will be responsible for all fines imposed by the Fire Marshall. Please avoid the use of aerosol sprays as well. These products may also set off the fire alarm. In case of a fire alarm, by law, the building must be evacuated. The technologist assigned to you will disconnect you and give you instructions. PLEASE DO NOT ATTEMPT TO DISCONNECT YOURSELF. The Niolopua Sleep Wellness Center video recording policy is as follows: THERE IS A CAMERA IN EACH ON THE PATIENT ROOMS. Your study will be recorded for diagnostic purposes and also for your safety as well as for the safety of our staff. Recording starts at time of setup. PLEASE UNDRESS/DRESS BEFORE SETUP BEGINS Please inform your technologist if you would like to change clothes in the bathroom. The video is the property of Niolopua Sleep Wellnes Center at Manakai O Malama. Our physicians will decide whether or not to save the video for diagnostic purposes. IF THERE IS NO CLINICAL REASON TO SAVE THE VIDEO, WE RESERVE THE RIGHT TO DESTROY IT. By signing this form, I confirm that I have read and understand the above policies at the Niolopua Sleep Wellnes Center. Signature Date

4 HAWAII PRIVACY OF HEALTH CARE INFORMATION In accordance with the American Medical Association Code of Ethics, we believe that the patient-physician relationship is based on trust and confidentiality of communication. The free and uninhibited disclosures of personal information within this relationship are the cornerstone of good medical care. The privacy of your medical records is of the utmost importance to our staff and us. We have therefore taken measures to ensure that your medical records receive the highest level of confidentiality and security. This office adheres to the following procedures to ensure protection of your private medical records. Our office staff has received education and training regarding the use and handling of patients protected health information. Your records are secured in this office. Access to office keys is limited to our doctors, staff, and bonded cleaning crew. Access to electronic information is only released as required or permitted by state of federal law. AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION, hereby authorize Niolopua Sleep Wellness Center at (Patient, parent or legal guardian) Manakai O Malama Integrative Healthcare Group to disclose health information, including copies or summaries of medical records for to: (Name of patient) a. Any health insurance plan or company that provides insurance coverage for the purpose of payment of charges. b. To health care providers to whom have referred the patient to this office for care, for the purposes of coordination of medical care. This authorization shall cover the period of time from my first visit to my last visit. I understand that I can revoke this authorization at any time. This authorization shall end two years after the date of my last visit. Signature Date For Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign Communication barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please Specify):

5 Patient Evaluation of Services Date: Please help us to better meet our patient needs and improve our services: 1. Did you have any trouble scheduling your appointment? Yes No If yes, please comment below: 2. Was the Niolopua Sleep Lab easy to find? Yes No If no, please comment below: 3. Circle the number that best describes your opinion. Room Very Comfortable Uncomfortable Room Temperature Bed Comfort Appearance of the Room Staff Friendliness/Professionalism Overall Service of Sleep Staff Have you had a previous sleep study? Yes No If yes, how do we compare with the other lab? Better About the same Worse 5. Based on your overall experience with us, would you recommend us to others needing a sleep study? Yes No If no, please comment below: 6. Please list any additional comments or suggestions that you would like to make: 7. Only if you had a particular problem and would like a member of our administrative staff to contact you, please list your name and telephone number below: Thank you for helping us to improve our quality of care!!! Niolopua Sleep Wellness Center Staff

6 TEST RESULTS Please do not call the laboratory for your results. AFTER YOUR SLEEP STUDY, PLEASE WAIT FOR YOUR PRIMARY CARE PHYSICIAN OR NIOLOPUA SLEEP SPECIALIST TO CALL YOU FOR A FOLLOW-UP APPOINTMENT Your sleep study will be scored and interpreted by our sleep medicine physicians. Due to the complexity and large amounts of raw data collected this process usually takes approximately 7-10 business days. Your results will be reviewed with you during your follow-up appointment with a staff sleep specialist or with your referring physician. You will have a follow-up visit with your Primary Healthcare Provider or a Niolopua Sleep Specialist to discuss the results of your study. It is preferred that you wait until the sleep study results are available before the follow-up appointment is scheduled. Sleep study results are not generally discussed over the telephone because of their complex nature. To fully understand the results of your sleep study, their implications, and treatment options, you should meet face-toface with a healthcare professional OUR TECHNOLOGIST ARE NOT PERMITTED TO INFORM PATIENTS OF ANY RESULTS OR GIVE ANY TREATMENT RECOMMENDATIONS. Please discuss any medical issues with and address all questions to your physician. The technologists are here to perform and ensure an accurate study and may only answer questions related to conducting the test and discuss general education regarding sleep. Please refrain from asking the technologist about the results, discussions of findings during the study are not permitted. If you have any questions or comments regarding our policies, please feel free to call us during daytime business hours Monday through Friday at PLEASE TAKE THIS SHEET HOME WITH YOU THANK YOU!