Skip to content
(205) 933-9258Email Us
Patient Portal
Birmingham Pulmonary
Birmingham’s Pulmonary Specialists
Birmingham Pulmonary
  • Home
  • Meet Our Providers
  • Services
  • Resources
  • Testimonials
  • Forms
    • 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

MM slash DD slash YYYY
Symptoms that apply to you:(Required)
Medical History:(Required)

Operations:

Hospitalization(s) in past 12 months:

Family History: Please list any major health problem(s), if deceased list the age of occurrence and cause of death:
Personal History:
1. Do you Smoke:(Required)
2. Alcohol consumption:(Required)
3. Caffeine daily consumption:
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
3. Do you take naps?
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
When you are angry
When hearing or telling a joke
When tense or under stress
During exercise
5. Are your dreams so real that you cannot tell if you are awake or asleep?
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?
7. Have you ever suffered a head injury, meningitis, encephalitis, stroke or seizures? □
8. Do you sleep better away from home?
9. Do you relate your sleep problems to a specific change or stress in your life?
10. If awakened do you feel it necessary to eat or drink in order to resume sleep?
11. Do you use prescription or over the counter medicines to help you sleep?
12.Do you typically have sleepiness associated with periods, PMS, or menopause?
13. Do you experience repetitive arm or leg movements while asleep?
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)
15. Do you talk in your sleep?
16. Do you grind or clench your teeth while you sleep?
17. Do you sleep walk?
18. Do you have episodes of extreme terror/ screaming during sleep, yet have little if any recall of the event
19. While asleep, have you ever acted out a dream or injured yourself or bed partner?
20. Do you have episodes of bed-wetting during sleep? (More than once a month)
21. Do you cough at night?
22. Do you work at night or change shifts?
Get In Touch

 

Submit

Contact Info

Birmingham Pulmonary Group, PC

St. Vincent’s Hospital
800 Saint Vincent’s Drive
Suite 600
Birmingham, AL 35205

Phone: (205) 933-9258
Fax: (205) 933-6504

Office Hours

Monday – Thurs.  8:00 am – 4:00 pm

Friday 8:00 am – 12:00 pm


 

Ⓒ Birmingham Pulmonary Group, PC. All rights reserved.

Go to Top