Form | Commonwealth Sleep Center

PATIENT INFORMATION

Date

Last Name

Middle Initial

First Name

Date of Birth

Age

Social Security:#

Sex

Home Address

Address Line 1

Address Line 2

City

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

State

Zip Code

Phone Number #:

Fax #:

Family Physician (If different from Referring):

Family Physician’s Name:

Physician’s Address:

Address Line 1

City

State

Zip Code

Phone Number #:

Fax #:

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?

If YES, please provide us the sleep study reports

Are you currently using CPAP / BiPAP?

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?

Do you have excessive daytime sleepiness?

Section 1: Screening questions for SLEEP APNEA:

Do others complain about your snoring?

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?

Do you awaken from sleep short of breath or with a feeling of being choked?

Do you have nighttime sweating?

Do you have morning headaches?

Do you have multiple nocturnal awakenings? What wakes you up, when, how many times a night?

Weight gain or loss over the past 12 months?

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: STOP

S- Do You Snore Loudly (louder than talking or loud enough to be heard through closed doors)?

T- Do you often feel TIRED, fatigued, or sleepy during the day?

O- Has anyone OBSERVED you stop breathing during your sleep?

P- Do you have or are you being treated for high blood PRESSURE?

BANG

B- Is your BODY MASS INDEX (BMI) more than 28?

A - AGE-Are you over 50 years old?

N- Are you a man with a NECK circumference greater than 17 inches or a woman with a NECK circumference greater than 16 inches?

G - Gender - Are you a male?

Total Yes Score

High Risk of OSA: Yes- 5-8
Intermediate Risk of OSA: Yes 3-4
Low Risk of OSA: Yes- 0-2

Section 4: 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)

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)

Do you feel paralyzed when waking or falling asleep? (Sleep Paralysis)

Do you fall asleep at inappropriate times or experience sleep attacks?

Section 5: Screening questions for INSOMNIA

Check if you are currently diagnosed with:

Depression
Anxiety

Do you routinely require more than 30 minutes to fall asleep?

Do you wake up several times during the night and can't get back to sleep? What causes you to wake up?

Do you often wake up one or two times before scheduled wake time and can't get back to sleep?

Do you have thoughts racing through your mind while trying to fall asleep?

Do you read, watch TV, or use a laptop in bed?

Do you deliberately sleep less in order to do other things?

If yes, please specify

nights/week

Nights

hrs/night

When you try to sleep, does worrying or problem solving often keep you awake?

Do you often lose sleep because your bed partner disturbs you at night?

Section 6: Insomnia Severity Index

The Insomnia Severity Index has seven questions. The seven answers are added up to get a total score. When you have your total score, look at the 'Guidelines for Scoring/Interpretation' below to see where your sleep difficulty fits. For each question, please MARK what best describes your answer. Please rate the CURRENT (i.e. LAST 2 WEEKS) SEVERITY of your insomnia problem(s). PLEASE NOTE YOU MUST HAVE A NUMBER IN EACH SECTION.

Difficulty falling asleep (0-None, 1-Mild, 2-Moderate, 3-Severe, or 4-Very Severe) *

Difficulty staying asleep (0-None, 1-Mild, 2-Moderate, 3-Severe, or 4-Very Severe) *

Problems waking up too early (0-None, 1-Mild, 2-Moderate, 3-Severe, or 4-Very Severe) *

How SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern? (0-Very Satisfied, 1-Satisfied, 2-Moderately Satisfied, 3-Dissatisfied, or 4-Very Dissatisfied) *

How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life? (0-Not at all Noticeable, 1-A Little, 2-Somewhat, 3-Much, or 4-Very Much Noticeable) *

To what extent do you consider your sleep problem to INTERFERE with your daily functioning (e.g. daytime fatigue, mood, ability to function at work/daily chores, concentration, memory, mood, etc.) CURRENTLY? (0-Not at all Interfering, 1-A Little, 2-Somewhat, 3-Much, or 4-Very Much Interfering) *

How WORRIED/DISTRESSED are you about your current sleep problem? (0-Not at all Worried, 1-A Little, 2-Somewhat, 3-Much, or 4-Very Much Worried) *

Total score categories:

0-7= No clinically significant insomnia
8-14= Subthreshold insomnia
15-21= Clinical insomnia (moderate severity)
22-28= Clinical insomnia (severe)

Section 7: Screening questions for RESTLESS LEG MOVEMENTS SYNDROME / PERIODIC LEG OF SLEEP

Do you have leg cramps at bedtime?

Do you experience crawling and achy feelings in your legs during the day or night which makes you want to move them or

Do you notice that these feelings in your legs are worse at night time?

Do the symptoms occur with (or are worsened by) rest?

Do you have relief with movement?

Do you wake yourself with body jerks (arms or legs)?

Have you been told that your legs or arms move every 20 seconds or so during the night?

Are your bedcovers in total disarray in the morning?

Section 8: 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?

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?

Have you been told you sleepwalk?

Have you been told you arouse from sleep totally confused or are inconsolable?

Have you awakened feeling panicked with your beating uncontrollably?

Do you have a history of seizures?

Section 9: 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)

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)

Does your job require you to work different shifts?

Section 10: Screening questions for BRUXISM

Do you have morning jaw pain?

Do you grind your teeth during sleep?

Section 11: Other - WEIGHT LOSS AND WELLNESS

Are you concerned about your weight?

Have you had significant weight loss? How much and over what period of time?

Have you had significant weight gain? How much and over what period of time?

Section 12: Other - NASAL OR BREATHING OBSTRUCTION

Do you have problems breathing through your nose especially at night?

Does the nasal blockage come and go?

Is your nasal blockage constant?

Is one side always worse than the other?

Section 13: 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 14: FAMILY HISTORY Have any members of your family (blood kin) had:

Heart disease

High blood pressure

Diabetes

Have any immediate family members been diagnosed with or treated for a sleep disorder?

If yes, please explain:

Section 15 ALLERGIES

Allergies

No Known Allergies
Other

Section 16: PERSONAL MEDICAL HISTORY

Arrythmia

Asthma

Congestive Heart Failure

COPD

Coronary Artery Disease

Dementia

Diabetes

Heart Attack

Hypertension

Migraine

Neuromuscular Impairment

Seizure

Stroke

Other medical history:

Section 17: SURGICAL HISTORY

Please choose any Head / Nose / Throat / Surgeries

Tonsillectomy

Adenoidectomy

Sinuplasty

Uvulopalatopharyngoplasty (UPPP)

Septoplasty

Any other Major surgical history:

Section 18: MEDICATION LIST

Medication

Dose

How often

Reason

Medication

I Agree

I acknowledge that I have received the Notice of Privacy Practices from Commonwealth Sleep Center office. I understand that if I have questions regarding this notice, I may contact the Privacy Officer at the above address. I indicate below the names of the any person (s) to whom I would like Commonwealth Sleep Center office to allow disclosure of Individually Identifiable Health Information (IIHI), e.g. labs, x-rays, health conditions, prognosis and diagnosis, appointments and prescription information.

NAME

RELATIONSHIP:

ALLOWED DISCLOSURES

(Limited or All)

PLEASE PROVIDE A PHONE NUMBER THAT YOU WISH TO BE CONTACTED BY OUR OFFICE ABOUT APPOINTMENTS AND TEST RESULTS

(Limited or All)

Signature of Patient or Legal Guardian

First Name of Patient or Legal Guardian

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