HOME SLEEP STUDY - PATIENT QUESTIONNAIRE DATE:

Who is the Physician ordering the Sleep Study?

Who is the primary care Physician?

Do you want this report sent to another Physician?

PERSONAL INFORMATION

Patient’s Name: First: Middle Initial: Last: Sex: Male Female

Date of Birth: Email: Age

Home Address: Home Phone #:

Cell Phone #:

Work Phone #:

Place of Employment: Occupation: Weight: lbs. Height: ft in

EMERGENCY CONTACT PERSON:

Name: Relationship: Home Phone #: Cell Phone #:

INSURANCE INFORMATION

Primary Insurance:

Secondary Insurance:

(Complete only if you are not the Insurance Policy Holder)

Policy Holder Name: First: Middle Initial: Last:

Relationship:

Policy Holder’s Address:

Policy Holder’s Date of Birth:

City:

State:

ZIP Code:

1

You have two options for completing a questionnaire:- Enter the information on the fillable PDF and click ‘Print’ at the end of the document - Print the questionnaire and fill it out by hand

The Authorization Signature must be completed by hand.Please bring the completed questionnaire(s) to the office or sleep lab.

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 patient 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

Sign: Date:

SNORING/SLEEP APNEA QUESTIONNAIRE

HISTORY OF SNORING Yes No

HAVE YOU BEEN TOLD THAT YOU STOP BREATHING DURING SLEEP Yes No

RESTLESS / UNREFRESHED SLEEP Yes No

RESTLESS LEGS Yes No

DAYTIME SLEEPINESS / NAP Yes No

DAYTIME FATIGUE/ LACK OF ENERGY Yes No

HISTORY OF MEMORY LOSS Yes No

DIFFICULTY TO CONCENTRATE Yes No

DO YOU FEEL IRRITABLE/CRABBY Yes No

DO YOU SUFFER FROM DIMINISHED SEXUAL DRIVE? Yes No

DO YOU WAKE UP FROM SLEEP? Yes No

DO YOU SUFFER FROM INSOMNIA/DIFFICULTY SLEEPING Yes No

DO YOU SUFFER FROM DEPRESSION Yes No

HISTORY OF HEART DISEASE, HEART FAILURE, ATRIAL FIB Yes No

DO YOU HAVE PACEMAKER/ DEFIBRILLATOR Yes No

HISTORY OF STROKE, TIA, MUSCLE WEKNESS, MS, ALS Yes No

HISTORY OF HYPERTENSION Yes No

HISTORY OF FIBROMYALGIA, CHRONIC FATIGUE Yes No

UNEXPLAINED WEIGHT GAIN? Yes No

HAVE YOU HAD PREVIOUS SLEEP STUDY? Yes No

HAVE YOU USED CPAP IN THE PAST? Yes No

THE STOP QUESTIONNAIRE

1. Do you SNORE loudly? Yes No

2. Do you often feel TIRED, fatigued, or sleepy? Yes No

3. Have you been OBSERVED to stop breathing during sleep? Yes No

4. Are you being treated for high blood PRESSURE? Yes No

2

EPWORTH SLEEPINESS SCALE

How likely are you to doze off or fall asleep in the situations described below, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you haven't 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 1 = SLIGHT CHANCE OF DOZING 2 = MODERATE CHANCE OF DOZING 3 = HIGH CHANCE OF DOZING

SITUATION CHANCE OF DOZING

Sitting and Reading 0 1 2 3

Watching TV 0 1 2 3

Sitting, inactive in a public place (eg, a theater or meeting) 0 1 2 3

As a passenger in a car of an hour without a break 0 1 2 3

Lying down to rest in the afternoon when circumstances permit 0 1 2 3

Sitting and talking to someone 0 1 2 3

Sitting quietly after a lunch without alcohol 0 1 2 3

In a car, while stopped for a few minutes in traffic 0 1 2 3

Total

Please bring this completed form (with signature) and also your insurance card when you come to the office / sleep lab.

3