Patient Sleep Survey | Serene Sleep Center, Flint, MI

Today's Date:

Name:

DOB:

Height:

Weight

Sex:

Male

Female

Referring doctor:

Other physicians:

Best time of day to reach you:

Phone:

Please explain why you were referred to the sleep center:

Have you had a sleep study before this?

Yes

No

If yes, when and where?

Are you currently using a CPAP?

Yes

No

Usual bedtime:

Usual wakeup time:

How long does it take for you to fall asleep?

After you sleep, how many times do you wake up each night?

Why do you wake up?

Do you fall back asleep quickly?

Hours of sleep during Nap-time:

Hours of sleep during Night-time:

If you wake up early in the morning, do you have trouble falling back asleep?

Yes

No

If yes, how long are you awake before getting up?

Have you noticed either of the following?

Leg jerking during sleep?

Yes

No

Creeping feeling in your legs preventing you from falling asleep?

Yes

No

Sleep History

Sleep History

Do you snore?

Yes

No

If yes, describe how loud?

Does your snoring wake you?

Yes

No

Does the snoring disturb your bed partner?

Yes

No

Has anyone ever told you that you stop breathing when you are asleep?

Yes

No

Do you wake up choking or gasping

Yes

No

Do you wake up with a headache?

Yes

No

Do you have nasal stuffiness or congestion during sleep?

Yes

No

Do you have action packed dreams?

Yes

No

Does any pain or physical discomfort disrupt your sleep?

Yes

No

If yes, please explain:

Do you ever wake up from sleep and feel unable to move?

Yes

No

When you are excited, do you lose muscle strength?

Yes

No

Do you walk in your sleep?

Yes

No

Do you have a problem with bed wetting?

Yes

No

Do you yell during sleep?

Yes

No

Do you grind your teeth during sleep?

Yes

No

Do you act out your dreams in your sleep?

Yes

No

Do you have any sexual problems?

Yes

No

Are you tired during the day?

Yes

No

Are you sleepy during the day?

Yes

No

How do you feel when you get up in the morning? Please describe:

Do you get sleepy while driving?

Yes

No

If yes, please explain:

Do you get sleepy while working?

Yes

No

If yes, please explain:

Do you get sleepy while siting?

Yes

No

If yes, please explain:

Do you get sleepy while in meetings?

Yes

No

If yes, please explain:

Is this sleepiness bothering you? If yes, please explain:

How are you coping with the sleepiness?

Have you had any recent life changes, stress or concerns? If yes, please explain:

Do you have anxiety or panic attacks? If yes, please explain:

Do you feel depressed or frustrated? If yes, please explain:

IF YOU ARE CURRENTLY USING A CPAP PLEASE COMPLETE THE FOLLOWING:

How many nights a week are you using the CPAP?

How many hours a night do you use CPAP?

Are you having any problems using the CPAP? If yes, please explain:

What is the pressure setting on your machine?

Have you had surgery for sleep apnea? If yes, when?

Family History

Family History

Do you have family members who have a history of snoring?

Yes

No

Has any family member been diagnosed with sleep apnea?

Yes

No

Additional Information

Additional Information

1. What is your occupation?

2. What shift do you work?

3. Please describe your work:

4. Do you smoke? If yes, how much?

5. Do you drink caffeinated beverages?

Yes

No

If yes, how much per day of the following?

If yes, how many cups per day of the following?

Coffee (cups per day):

Tea (cups per day):

Soda (cups per day):

Other (cups per day):

Do you drink alcohol? If yes, how much?

Do you use recreational street drugs? If yes, what kind?

Have you had unexplained changes in weight of more than 10 pounds in the last six months?

Yes

No

Gain:

Loss:

Is there any other information that you want the physician to know?

Medical History

Medical History

1. Hypertension

Yes

No

Explain:

2. Heart Problems

Yes

No

Explain:

3. Lung problems

Yes

No

Explain:

4. Diabetes

Yes

No

Explain:

5. Thyroid problems

Yes

No

Explain:

6. Epilepsy or seizures

Yes

No

Explain:

7. Stroke or other neurological problems

Yes

No

Explain:

8. Kidney disease or dialysis

Yes

No

Explain:

9. Sinus or nose problems

Yes

No

Explain:

10. Heartburn

Yes

No

Explain:

11. Mental Health problems

Yes

No

Explain:

Other:

List all surgeries:

Are you currently on home oxygen?

Yes

No

If yes, how many liters per minute?

Do you have any special needs? (use walker, need hospital bed, need help with daily activities, etc.)

Medication List

Medication List

Date:

Pharmacy name:

Address:

Pharmacy Phone:

List of allergies (drugs, latex, foods, etc)

Current Medications (Prescriptions, OTC, herbals, patches, inhalers, eye drops, etc)

Current Medications (Prescriptions, OTC, herbals, patches, inhalers, eye drops, etc)

Please list all current medications below (include strength, how it is taken, and number of times taken per day)

Epworth Sleepiness Scale

Epworth Sleepiness Scale

Date:

directions

How likely are you to doze off or fall asleep in the following siutations, in onctrast to feeling just tired? this refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you.

scale

Use the following scale to choose the most appropriate number for each situation.

Would never dose = 0

Slight chance of dozing = 1

Moderate chance of dozing = 2

High chance of dozing = 3

Sitting and reading

0

1

2

3

Watching TV

0

1

2

3

Sitting, inactive, in a public place (e.g. theater or a meeting)

0

1

2

3

As a passenger in a car for 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 with 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 Number (add up all scores):

Billing

Billing

Free Text

There will be seperate billing for the physician's interpretation of the sleep study. If there is insurance, the insurance company will be billed for this service. Any remaining balance will be the responsibility of the patient.

If the insurance company requires an authorization prior to the interpretation of this sleep study, referrals are the responsibility of the patient. The insurance company is likely to deny payment for the services rendered if a referral is not provided from the primary physician. The physician specialist will bill the insurance for the services; however, if the insurance denies payment, the patient agrees to be personally and fully responsible for payment. Also, an additional collection fee will be added to the account if any balance remains due after 60 days.

Patient Signature:

Today's Date

Adult Questionnaire

Contact Us

Serene Sleep Center

1125 S. Linden Road, Suite 270

Flint, MI 48532

Phone: 810-600-7000

Fax: 810-422-9131