Questionnaire - Sound Asleep Lab

"*" indicates required fields

PATIENT DEMOGRAPHICS

Please provide photos of your driver's license and insurance cards (front and back with mobile phone)

Email the photos of your driver's license and insurance cards to info@soundasleeplab.com (On the subject line type your name and date of birth)

Bring the printed materials for office visit or you could fax it to 989-793-7113 or 989-792-1792

Who is the Physician that referred you to us?*

Who is the primary care Physician?*

Do you want this report sent to another Physician?

PERSONAL INFORMATION

Name*

First Middle Initial Last

Sex

Male

Female

Date of Birth*

Age

Home Address*

Street Address Address Line 2 City State Zip

Cell Phone*

Home Phone

Work Phone

Place of Employment

Occupation:

Weight*

Height

Feet*

Inches*

BMI

EMERGENCY CONTACT PERSON

Name*

Relationship

Cell Phone*

Home Phone

PHARMACY*

Pharmacy Location*

INSURANCE INFORMATION

Primary Insurance Name*

Policy#

Secondary Insurance Name

Policy#

(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

Street Address Address Line 2 City State Zip

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 the patient’s 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.

I authorize and agree by checking this box and typing my name below

Your Name*

Date*

Do you or have you been told that you….

Do you snore / have been told you snore*

Yes

Hold your breath or stop breathing during sleep?*

Yes

Have difficulty sleeping on your back or trouble breathing while lying flat?*

Yes

Have daytime sleepiness / fatigue?*

Yes

Having achy or restless legs?*

Yes

Wake up gasping and/or choking?*

Yes

Have an itching or crawling sensation in your legs?*

Yes

Unable to fall asleep due to "restless legs"?*

Yes

Take naps?*

Yes

At times, have to struggle to stay awake?*

Yes

Have a problem with your performance at work due to sleepiness / fatigue?*

Yes

Wake up with morning headaches?*

Yes

Have restless sleep?*

Yes

Do you toss and turn in bed?*

Yes

Walk in your sleep?*

Yes

Talk in your sleep?*

Yes

Grind your teeth?*

Yes

Wet the bed (as an adult)?*

Yes

Disturb the sleep of your bed partner?*

Yes

Have disturbed sleep due to bed partner?*

Yes

Awaken from sleep due to screaming or violence?*

Yes

Have heartburn or gas during the night?*

Yes

Wake up with a burning sensation in your throat?*

Yes

Sweat excessively during sleep?*

Yes

Eat during the night without being aware you do so?*

Yes

Have a persistent cough at night?*

Yes

Have frequent need to urinate while sleeping (more than twice)?*

Yes

Have nasal congestion?*

Yes

Do you suffer from Insomnia (trouble sleeping)?

Yes

What time do you go to sleep?

What time do you get out of bed?

How many hours of sleep do you get each night?

How many nights per week do you get decent sleep?

Do you have trouble falling asleep at night?

Yes

How long does it take for you to fall asleep?

Do you have trouble staying asleep once you fall asleep?

Yes

How many times do you wake up from sleep?

Do you have trouble falling back to sleep?

Yes

How long does it take for you to fall back to sleep?

List of prescription medications you have taken so far to fall asleep or stay asleep?

Have you seen anyone other than your PCP for Insomnia?

Yes

Please specify

How often do you…

Take naps?*

Never

Sometimes

Always

Feel refreshed after you nap?*

Never

Sometimes

Always

Experience dream-like images while falling asleep?*

Never

Sometimes

Always

Have episodes of muscular weakness when laughing, angry, or any extreme emotional situation?*

Never

Sometimes

Always

Ever feel paralyzed when waking up?*

Never

Sometimes

Always

Excessively sleepy during normal wake hours?*

Never

Sometimes

Always

Feel refreshed upon waking up?*

Never

Sometimes

Always

How many times have you had a near auto accident (driving off the shoulder of the road) due to sleepiness?*

How many times during the night do you wake up?*

Have you previously been tested for a sleep disorder?*

Yes

If yes, please list: When

and Where

Are you being treated for this condition?

Yes

Have you ever used CPAP/BiPAP?*

Yes

If yes, since which year?

Are you currently using CPAP/BiPAP?*

Yes

Agency/ DME Name where you get CPAP/ Mask & Other Supplies

Agency Name

Location

Agency/ DME Name where you get CPAP/ Mask & Other Supplies

Don't Know

Are you currently using oxygen?*

Yes

Agency/ DME Name where you get Oxygen & other Supplies

Agency Name

Location

Agency/ DME Name where you get Oxygen & other Supplies

Don't Know

Have you had your tonsils or adenoids removed or palatoplasty (surgical procedure) for sleep apnea?*

Yes

Are you or have you ever been treated for the following:

Diabetes*

Yes

High Blood Pressure*

Yes

Heart Disease (heart failure/A-FIB/heart attack/palpitation/irregular heart)?*

Yes

Please specify

Do you have a pacemaker / defibrillator?*

Yes

COPD / Emphysema / Asthma?*

Yes

Please specify

Do you use oxygen at home (Day / Night)?*

Yes

Heart burn / Reflux / Hiatal hernia*

Yes

Daytime Sleepiness*

Yes

Hypothyroidism*

Yes

Chronic Back / Neck or Hip pain?*

Yes

ADD/ADHD?*

Yes

Difficulty concentrating/focusing/memory loss?*

Yes

Please specify

Depression/Anxiety/PTSD*

Yes

Please specify

Insomnia*

Yes

Neurological condition (Stroke /MS/ Parkinson’s/TIA/Memory Loss/Seizure)*

Yes

Please specify

Muscular skeletal disorders (Fibromyalgia / Muscle weakness)*

Yes

Please specify

Rheumatism, Rheumatoid Arthritis, Lupus, or Osteoarthritis*

Yes

Please specify

Sleep related eating disorders?*

Yes

Kidney Disease/Failure*

Yes

Please list any other pertinent medical conditions you are currently being treated for.

Which shift are you currently working?*

Do you drink alcohol in excess?*

Yes

Do you smoke?*

Yes

Packs per day

Quit date

Please list any medications you are currently taking, including any medications that you have taken in the past 3 months. Please be sure to specify the dosage and the time of day you take them. Click the + button to add each medication. (**unless otherwise instructed by the physician that ordered your sleep study, continue to take all medications as usual.)

MEDICATION LIST & DOSAGE

Are you allergic to any medications?*

Yes

If yes, please list:

EPWORTH SLEEPINESS SCALE

(Consider at the worse time of the day and in worse situation. This is required to get pre-authorization for your sleep study)

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 DOSE
1 = SLIGHT CHANCE OF DOZING
2 = MODERATE CHANCE OF DOZING
3 = HIGH 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

STOP-BANG Questionnaire

Do you snore loudly?*

Yes

Do you often feel tired, fatigued or sleepy?*

Yes

Have you been observed to stop breathing during sleep?*

Yes

Do you have high blood pressure?*

Yes

BMI – (Weight/height Index) over 35? BMI Calculator*

Yes

Are you over 50 years of age?*

Yes

Is your collar size over 16 inches for male, or 14 inches for female?*

Yes

Check the box below

Comments

This field is for validation purposes and should be left unchanged.

Please bring the printed materials for office visit or you can fax it to 989-793-7113 or 989-792-1792.