GAINESVILLE
7001 Heritage Village Plaza, Suite 120 Gainesville, VA 20155
WOODBRIDGE
2200 Optiz Blvd, Suite 335 Woodbridge, VA 22191
ALEXANDRIA
4216 King St, Alexandria, VA 22302.
571-261-9877
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HOME
NEW PATIENTS
PATIENT FORMS
SLEEP INSTRUCTION
SLEEP ISSUES
PATIENT INFO
APPOINTMENTS & SCHEDULING
PATIENT FORMS
PATIENT PORTAL
EPAYMENT
SERVICES
OUR FACILITY
SLEEP STUDY
In-Lab Study
PSG
CPAP
Home sleep study
PROVIDERS
ABOUT US
DOCTORS
DME
EQUIPMENT & SUPPLIES
RESUPPLIES
VIDEOS
CONTACT
Form
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Step
1
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PATIENT INFORMATION
Date
Last Name
Middle Initial
First Name
Date of Birth
Age
Social Security:#
Sex
Male
Female
Transgender
Home Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Work Phone #
Home Phone #
Mobile Phone #
Email Address
Marital Status:
Single
Married
Divorced
Widow
Emergency Contact Name
Phone
Relationship
INSURANCE INFORMATION
Primary Insurance Name
Effective Date
Occupation:
Employer
Insurance Policy
Group
Policy Holder’s Name:
Policy Holder’s DOB:
Secondary Insurance Information
Policy # :
Group #:
REFERRING PROVIDER INFORMATION
Referring Physician Name:
Physician’s Address:
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number #:
Fax #:
Family Physician (If different from Referring):
Family Physician’s Name:
Physician’s Address:
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number #:
Fax #:
Next
SCREENING QUESTIONS - SLEEP HISTORY
Patient Name:
Patient's Date of Birth:
Height:
(Inch)
Weight:
(LB)
Neck size:
(Inch)
BMI
Have you ever had a sleep study?
Yes
No
N/A
If YES, please provide us the sleep study reports
Are you currently using CPAP / BiPAP?
Yes
No
N/A
What is your primary sleep problem?
How long have you had that problem?
What time do you usually go to bed and get up?
Week days
Week ends
How many nights a week do you get:
8+ hours of sleep?
nights
7 hours of sleep?
nights
6 hours of sleep?
nights
5 or less hours of sleep?
nights
How often do you nap?
week
for how long
min
Do you wake up feeling refreshed?
Yes
No
N/A
Do you have excessive daytime sleepiness?
Yes
No
N/A
Back
Next
Section 1: Screening questions for SLEEP APNEA:
Do others complain about your snoring?
Yes
No
N/A
Has anyone witnessed you during an apneic event? (Have you experience when there is no snoring followed by a loud snort to a body jerk?) If so, how often?
Yes
No
N/A
Do you awaken from sleep short of breath or with a feeling of being choked?
Yes
No
N/A
Do you have nighttime sweating?
Yes
No
N/A
Do you have morning headaches?
Yes
No
N/A
Do you have multiple nocturnal awakenings? What wakes you up, when, how many times a night?
Yes
No
N/A
Weight gain or loss over the past 12 months?
Yes
No
N/A
Section 2: EPWORTH SLEEP SCALE
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? Use the following scale and indicate the most appropriate number for each situation:
0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing
Situation (Change of Dozing)
Sitting and reading
Watching TV
Sitting, inactive, in a public place (ie., school or movie)
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 to someone
Sitting quietly after lunch
In a car, while stopped for a few minutes in traffic
Total (Range 0-24):
Section 3: Screening questions for NARCOLEPSY
Includes the uncomfortable urge to sleep during the day, especially during emotional events (feeling happy, sad, or mad)?
Do you feel your knees buckle, arms feel weak, or jaw drop with strong emotions? (Cataplexy)
Yes
No
N/A
Do you experience vivid dream-like episodes or scenes upon awakening or falling asleep that you can't tell whether they are real or not? (Hypnagogic Hallucinations)
Yes
No
N/A
Do you feel paralyzed when waking or falling asleep? (Sleep Paralysis)
Yes
No
N/A
Do you fall asleep at inappropriate times or experience sleep attacks?
Yes
No
N/A
Back
Next
Section 4: Screening questions for RESTLESS LEG MOVEMENTS SYNDROME / PERIODIC LEG OF SLEEP
Do you have leg cramps at bedtime?
Yes
No
N/A
Do you experience crawling and achy feelings in your legs during the day or night which makes you want to move them or
Yes
No
N/A
Do you notice that these feelings in your legs are worse at night time?
Yes
No
N/A
Do the symptoms occur with (or are worsened by) rest?
Yes
No
N/A
Do you have relief with movement?
Yes
No
N/A
Do you wake yourself with body jerks (arms or legs)?
Yes
No
N/A
Have you been told that your legs or arms move every 20 seconds or so during the night?
Yes
No
N/A
Are your bedcovers in total disarray in the morning?
Yes
No
N/A
Section 5: Screening questions for PARASOMNIAS (or things that go "bump" in the night including REM behavior disorder and include disorders of sleep walking or sleep talking)
Do you have nightmares?
Yes
No
N/A
Do you often move violently during your sleep while dreaming, and sometimes even hurt yourself or your partner by accident or fall out of bed?
Yes
No
N/A
Have you been told you sleepwalk?
Yes
No
N/A
Have you been told you arouse from sleep totally confused or are inconsolable?
Yes
No
N/A
Have you awakened feeling panicked with your beating uncontrollably?
Yes
No
N/A
Do you have a history of seizures?
Yes
No
N/A
Back
Next
Section 6: Screening questions for INSOMNIA
Check if you are currently diagnosed with:
Depression
Anxiety
Do you routinely require more than 30 minutes to fall asleep?
Yes
No
N/A
Do you wake up several times during the night and can't get back to sleep? What causes you to wake up?
Yes
No
N/A
Do you often wake up one or two times before scheduled wake time and can't get back to sleep?
Yes
No
N/A
Do you have thoughts racing through your mind while trying to fall asleep?
Yes
No
N/A
Do you read, watch TV, or use a laptop in bed?
Yes
No
N/A
Do you deliberately sleep less in order to do other things?
Yes
No
If yes, please specify
nights/week
Nights
hrs/night
When you try to sleep, does worrying or problem solving often keep you awake?
Yes
No
N/A
Do you often lose sleep because your bed partner disturbs you at night?
Yes
No
N/A
Section 7: Screening questions for CIRCADIAN RHYTHM DISORDER
Do you have trouble waking up in the morning and would rather stay up later (ie. Sleep at 2-3AM and wake up at noon?) (Delayed Sleep Phase - more common in adolescents)
Yes
No
N/A
Do you have to go to bed at 8PM only to find out that you wake up at 3AM? (Advanced Phase Syndrome - more common in elderly)
Yes
No
N/A
Does your job require you to work different shifts?
Yes
No
N/A
Section 8: Screening questions for BRUXISM
Do you have morning jaw pain?
Yes
No
N/A
Do you grind your teeth during sleep?
Yes
No
N/A
Back
Next
Section 9: Other - WEIGHT LOSS AND WELLNESS
Are you concerned about your weight?
Yes
No
N/A
Have you had significant weight loss? How much and over what period of time?
Yes
No
N/A
Have you had significant weight gain? How much and over what period of time?
Section 10: Other - NASAL OR BREATHING OBSTRUCTION
Do you have problems breathing through your nose especially at night?
Yes
No
N/A
Does the nasal blockage come and go?
Yes
No
N/A
Is your nasal blockage constant?
Yes
No
N/A
Is one side always worse than the other?
Yes
No
N/A
Section 11: SOCIAL HISTORY
Caffeine consumption: How much per day? ________ cups/day
cups/day
When do you typically consume your last serving of coffee?
Alcohol consumption: Type of drink
How many times?
/ wk
How many hours before bed?
/ wk
Smoking habits: How many packs per day?
Smoking habits: Over how many years?
Section 12: FAMILY HISTORY Have any members of your family (blood kin) had:
Heart disease
Yes
No
N/A
High blood pressure
Yes
No
N/A
Diabetes
Yes
No
N/A
Have any immediate family members been diagnosed with or treated for a sleep disorder?
Yes
No
N/A
If yes, please explain:
Section 13: ALLERGIES
Allergies
No Known Allergies
Other
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Next
Section 14: PERSONAL MEDICAL HISTORY
Arrythmia
Yes
No
N/A
Asthma
Yes
No
N/A
Congestive Heart Failure
Yes
No
N/A
COPD
Yes
No
N/A
Coronary Artery Disease
Yes
No
N/A
Dementia
Yes
No
N/A
Diabetes
Yes
No
N/A
Heart Attack
Yes
No
N/A
Hypertension
Yes
No
N/A
Migraine
Yes
No
N/A
Neuromuscular Impairment
Yes
No
N/A
Seizure
Yes
No
N/A
Stroke
Yes
No
N/A
Other medical history:
Section 15: SURGICAL HISTORY
Please choose any Head / Nose / Throat / Surgeries
Tonsillectomy
Yes
No
N/A
Adenoidectomy
Yes
No
N/A
Sinuplasty
Yes
No
N/A
Uvulopalatopharyngoplasty (UPPP)
Yes
No
N/A
Septoplasty
Yes
No
N/A
Any other Major surgical history:
Back
Next
Section 16: MEDICATION LIST
Medication
Dose
How often
Reason
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Back
Next
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