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1. Sleep Lab Appointment Instructions
2. Patient Information
3. Sleep Lab Form
Contact
Home
Meet Our Providers
Services
Resources
Testimonials
Forms
1. Sleep Lab Appointment Instructions
2. Patient Information
3. Sleep Lab Form
Contact
Sleep Lab Form
Patient Name
(Required)
Date
(Required)
MM slash DD slash YYYY
Please describe your sleep problem(s) and how long this has been a problem
(Required)
Symptoms that apply to you:
(Required)
Loud Snoring
Choking/Gasping during sleep
Excessive Daytime Sleepiness
Morning Headaches
Stop breathing during sleep (witnessed apnea)
Nasal obstruction/congestion
Wake w/ Dry Mouth
Difficulty Initiating or Maintaining Sleep
Wake feeling un-refreshed
Suffered an accident / injury due to falling asleep
None
Medical History:
(Required)
Cardiovascular Disease
Stroke
Hypertension
CHF
COPD
Neuromuscular
Disorders
Diabetes
Anxiety
Depression
Impaired Cognition
Asthma
Chronic Bronchitis
Sleep Apnea
Narcolepsy
Restless Legs
None
Operations:
YR
Operation(s)
YR
Operation(s)
YR
Operation(s)
YR
Operation(s)
Hospitalization(s) in past 12 months:
YR
Reason
YR
Reason
YR
Reason
YR
Reason
Medication(s):
Allergies: (medication/food/etc...)
Medication(s):
Allergies: (medication/food/etc...)
Medication(s):
Allergies: (medication/food/etc...)
Medication(s):
Allergies: (medication/food/etc...)
Family History: Please list any major health problem(s), if deceased list the age of occurrence and cause of death:
Father:
Mother:
Sister:
Brother:
Personal History:
1. Do you Smoke:
(Required)
No
Yes
Former Smoker
How long?
Pack(s) per wk
2. Alcohol consumption:
(Required)
Never
Rarely
Weekend's only
<= 2 oz liquor/beer/wine per day
2 oz per day
3. Caffeine daily consumption:
cups coffee
cups tea
cups soda
cups energy beverage
Sleep History: Epworth Sleepiness Scale: How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Use the following scale to enter the most appropriate number for each situation: 0= would never doze l = slight chance of dozing 2= moderate chance of dozing 3= high chance of dozing
While sitting and reading
0
1
2
3
While watching TV
0
1
2
3
While sitting inactive in a public place ( ex. a theater or meeting)
0
1
2
3
As a passenger in a car for an hour without a break
0
1
2
3
While lying down to rest in the afternoon when circumstances permit
0
1
2
3
While sitting and talking with someone
0
1
2
3
While sitting quietly after lunch without alcohol
0
1
2
3
While in a car stopped for a few minutes in traffic
0
1
2
3
Circle what best describes your overall sleepiness
None
Mild
Moderate
Severe
1. How many times a night do you typically awaken?
Epworth Total Score
2. How many hours per night do you sleep on average?
Mon-Thurs sleep time
Wake time
3. Do you take naps?
Yes
No
Fri-Sun sleep time
Wake time
how long in minutes
4. Do you or have you ever experienced episodes of muscle weakness, loss of muscle strength, or limp muscles in any part of your body during the following activities?
When you laugh
Yes
No
When you are angry
Yes
No
When hearing or telling a joke
Yes
No
When tense or under stress
Yes
No
During exercise
Yes
No
Other: If yes specify:
5. Are your dreams so real that you cannot tell if you are awake or asleep?
Yes
No
6. On occasion do you awaken soon after going to sleep or in the morning feeling paralyzed, unable to move or talk, which lasts only for a few seconds or minutes?
Yes
No
7. Have you ever suffered a head injury, meningitis, encephalitis, stroke or seizures? □
Yes
No
8. Do you sleep better away from home?
Yes
No
9. Do you relate your sleep problems to a specific change or stress in your life?
Yes
No
10. If awakened do you feel it necessary to eat or drink in order to resume sleep?
Yes
No
11. Do you use prescription or over the counter medicines to help you sleep?
Yes
No
12.Do you typically have sleepiness associated with periods, PMS, or menopause?
Yes
No
13. Do you experience repetitive arm or leg movements while asleep?
Yes
No
14. Do you have leg and/or arm discomfort when going to bed or when sitting still, which goes away by moving or walking? (Answer No, ifyourdiscomfort is muscle cramping)
Yes
No
15. Do you talk in your sleep?
Yes
No
16. Do you grind or clench your teeth while you sleep?
Yes
No
17. Do you sleep walk?
Yes
No
18. Do you have episodes of extreme terror/ screaming during sleep, yet have little if any recall of the event
Yes
No
19. While asleep, have you ever acted out a dream or injured yourself or bed partner?
Yes
No
20. Do you have episodes of bed-wetting during sleep? (More than once a month)
Yes
No
21. Do you cough at night?
Yes
No
22. Do you work at night or change shifts?
Yes
No
If yes, please describe.
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