Dear Sir Or Madame

Phone# 270-651-1888 1301 N. Race Street Glasgow, KY 42141 Fax # 270-651-1899

Dear Sir or Madame,

You have been referred to The T.J. Health Partners Sleep Clinic for evaluation (daytime office visit) of a possible sleep disorder.

Enclosed you will find three sleep questionnaires for your Sleep Consultation appointment. The Sleep History/Medical History Questionnaire should be completed by the patient or a caregiver. The Sleep Observer Questionnaire should be completed by your bed partner or someone who has observed your sleep. If you do not have a bed partner this questionnaire does not have to be completed.

Also enclosed is a Two Week Sleep Diary. This form should be completed over the next two weeks.

Please bring the diary to your first appointment, even if you have been unable to complete a full two weeks worth of information.

It is very important that these forms be filled out completely. Please bring the completed packet with you on the day of your consultation. This information will allow us to appropriately order the sleep study that best fits your needs.

Your sleep consultation has been scheduled for ______with our sleep clinic provider, atT.J.SamsonHospital. Please come directly to the sleep center at your scheduled time, directions are enclosed.

We will work with you and your insurance company to obtain any prior authorizations that are required.

If we can be of any assistance with answering any questions, please do not hesitate to call our office at (270) 651-1888.

Sincerely,

Lisa Pierce, RPSGT, CRT

Sleep Center Coordinator

Rev 07-15

Sleep Clinic

Phone# 270-651-1888 1301 N. Race Street Glasgow, KY 42141 Fax # 270-651-1899

DIRECTIONS TO THE

SLEEP CLINIC

The Sleep Disorders Clinic is located on the 2nd floor of T.J. Samson Hospital.

The most convenient place to park is outside the South Entrance

(formerly the old main entrance).

This entrance is opposite the building from the Emergency Room.

If you are coming from 31-E side of the hospital, this will be the 2nd entrance.

If you are coming from downtown (the square),

This will be the 1st entrance.

When you enter the hospital, walk up the hallway straight ahead and take the elevator on your left to the 2nd floor.

When you get off the elevator, look down the hall to the left, and you will see a large wooden door. This is the Sleep Lab entrance.

The Sleep Clinic is located on the right before you get to the Sleep Lab.

Signs will be posted.

Phone# 270-651-1888 1301 N. Race Street Glasgow, KY 42141 Fax # 270-651-1899
PATIENT INFORMATION
Legal Name: / Marital Status: / Single Divorced Widowed
Married Separated Other
Preferred Name: / / Sex: / Male Female Undefined
Date of Birth: / / / / Social Security: / - -
Address: / Referring Physician:
Primary Physician:
City, State, Zip: / Preferred Language: / English Spanish ______
Home Phone: / / Race: / American Indian or Alaska Native White
Black or African American Asian
Native Hawaiian or Other Pacific Islander Undetermined
Decline to Declare Race
Cell Phone:
Work Phone:
Email Address:
Contact By: / Letter Phone Cell Email / / Ethnicity: / Hispanic or Latino Non Hispanic or Latino
Decline to Declare Ethnicity
Pharmacy:
GUARANTOR (Responsible Party for Billing) / / REFERRAL INFORMATION
Same as patient Other: (fill out below) / How did you hear about us?
Name: / Physician Radio Patient Yellow Pages Internet
Address: / Name of Referral:
/ EMPLOYMENT INFORMATION
City, State, Zip: / Occupation:
Phone: / Employer:
Social Security #: / Employed Unemployed Retired Self Employed Other
Birthday: / Employment Date:
PRIMARY INSURANCE
Same Name as Patient Same as Guarantor Other / Address of Insured:
Name of Insured:
Date of Birth of Insured: / City, State, Zip:
Relation to Insured: Self Spouse Child Other / Home Phone of Insured:
Social Security of Insured: / Cell Phone of Insured:
Sex of Insured: Male Female / Work Phone of Insured:
SECONDARY INSURANCE
Same Name as Patient Same as Guarantor Other / Address of Insured:
Name of Insured:
Date of Birth of Insured: / City, State, Zip:
Relation to Insured: Self Spouse Child Other / Home Phone of Insured:
Social Security of Insured: / Cell Phone of Insured: / ______
Sex of Insured: Male Female / Work Phone of Insured:

I understand and agree that, (regardless of my insurance status), I am ultimately responsible for the balance on my account for any professional services rendered. I hereby authorize my insurance benefits to be paid directly to TJ Regional Health, LLC. I also authorize the physician to release any information required to process this claim. I certify that this information is true and correct to the best of my knowledge. I will notify you of any changes in my health status or the above information

Signature: ______Printed Name: ______Date: ______

Sleep History/Medical History Questionnaire

Patient Name: ______

Emergency Contact (outside of your home) Name: ______phone #: ______

Who is your primary care physician?

______

name address phone#

Who referred you?

______ name address phone #

How did you firsthear about our sleep center?

‪ from your physician ‪ newspaper article‪ radio‪ friend ‪ internet

‪ Other: ______

Through a series of questions for the review of systems this questionnaire is to help our physicians understand the nature of your complaints and possible sleep disorder. This information will be held in the strictest confidence. In order to assist us in serving you better, please answer each question completely and as accurately as possible.

CHECK ALL THAT APPLY:

( ) Daytime sleepiness ( ) Difficulty falling asleep ( ) Difficulty Staying Asleep ( ) Behaviors during sleep

( ) Not feeling rested in the morning ( ) Early awakening ( ) Other: ______

Please Describe Your Sleep Problem(s):______
How long have you had a sleep problem?______

How many nights a week do you have a sleep problem? ______

Have you had a prior sleep study? Yes NoWhen?______Where? ______

Do you use CPAP or BPAP ? Yes No (If yes bring your CPAP download card to your clinic visit)

if Yes please answer the questions below:

PAP equipment company ______CPAP or BPAP level ______

Mask: ( ) Nasal ( ) Full Type: ______Humidity? Heated Cool None

Problems with CPAP: ______

Have you had surgery for sleep apnea? Yes No If yes, Where? ______When?______

Are you on home oxygen? Yes No

If yes, who is your homecare/oxygen provider? ______

Which physician prescribed your oxygen? ______

How many hours a day?______hours
How many liters per minute during the day? ______liters/minute
How many liters per minute during the night?______liters/minute

Rev. 01-2013

SNORING AND BREATHING DURING SLEEP SYMPTOMS:

Do you snore?YesNoIf yes, is it:Mild ModerateLoudVery Loud

How often do you snore? Every NightUsuallySometimes
Has anyone told you that you stop breathing while asleep? Yes No
Do you sometimes wake up gasping for breath?Yes No

DAYTIME SLEEPINESS AND OTHER SYMPTOMS:

Do you have trouble staying awake during the day?YesNo
Do you have trouble at work or school because of sleepiness? YesNo
Do you have trouble staying awake while driving? Yes No
Do you ever feel weak (knees buckle) when emotional (anger, surprise, laughing)?

Yes No If yes, how long do the episodes last? ______How often do they occur?______

What triggers these episodes? ______

Do you ever feel paralyzed (can’t move) when falling asleep or waking up?Yes No

If yes, how often?______Describe the events ______

Do you have dreams or visions as you fall asleep or as you wake up?Yes No

If yes, how often? ______Describe the events ______

SLEEP QUALITY/HABITS:

On average, how do you feel when you get up in the morning (circle all that apply to you)?

RestedTiredSleepyGroggy Exhausted

Weekdays:Time to Bed: ______Time Awake: ______

Weekends:Time to Bed: ______Time Awake: ______

On average, how long does it take you to fall asleep? ______
On average, how many times do you wake up during the night? ______
On average, how long are you awake in the morning before you get up?______
On average, how many hours do actually sleep at night? ______
Do you take any kind of medications or use alcoholic beverages to help you fall asleep?YesNo

If yes, what do you take? ______

Do you take naps? Yes No if yes how long?______How often? ______
Can you see a clock face from your bed? YesNo
Approximately how much do you consume of the following beverages/foods daily?

Coffee w/caffeine ______Tea w/caffeine ______Soft Drinks w/caffeine ______

Chocolate ______Alcohol ______

Do your bedtimes and wake times vary? NoA little A lot
Do you work evenings, nights (3 to 11 PM or 11 PM to 7 AM) split or rotating shifts?

Yes_____No: _____If yes, please describe: ______

What is your usual sleeping position (check all that apply)? BackSideStomach

UNUSUAL BEHAVIOR DURING SLEEP:

Do you have any unusual behavior during sleep? Yes NoHow long have these occurred? ______

If yes, please check the type of behavior:

⁭ Sleep walking⁭ acting out dreams ⁭ talking⁭ Yelling or screaming ⁭violent behavior (hitting/swinging)

⁭ Lip smacking or unusual mouth movements ⁭ grinding teeth

Other behavior or activity: ______

LEG SYMPTOMS:

Do you ever feel like you just have to move your legs? YesNo
Do you ever have unpleasant creepy/crawly feelings in your legs? Yes No
Do you ever experience leg cramps at night?YesNo
Do these creepy/crawly feelings in your legs and the feeling like you have to move your legs ever occur at the same

time? Yes No

If yes:How often do this situation occur? ______

Do these feelings occur mainly when you are resting? YesNo

Do these feelings improve with movement?YesNo

Are these feelings worse in the evening than in the morning?Yes No

PAST MEDICAL HISTORY: (Please check all that apply)

⁭ Hypertension (high blood pressure)⁭ Diabetes ⁭ Depression⁭Chronic bronchitis/emphysema (COPD)

⁭ Stroke⁭Pacemaker ⁭ High cholesterol ⁭ Hepatitis ⁭ Angina/Heart attack ⁭ Chronic Fatigue ⁭Fibromyalgia

⁭ GERD (reflux) ⁭ Seizures Date of last Seizure: ______Date of last EEG: ______

⁭ Cancer If yes, type: ______Date diagnosed?______⁪ Post Traumatic Stress Disorder (PTSD)

GYN (women): Last menstral period Pregnancies Deliveries:______

Current Height: feet inches

Current Weight ______Weight 5 years ago ______Weight 10 years ago ______

Neck size: ______

REVIEW OF SYSTEMS: Please check all that apply to you:

General:

⁭ Weight loss⁭ Weight gain ⁭ Fevers⁭ Night sweats

Allergies

⁪Food Allergies⁪ Drug allergies⁪ allergies to insect bites

Immunization(date given):

⁭ Pneumonia Vaccination- Date ______⁭ Influenza Vaccination-Date______

Eyes:

⁭Change in vision ⁪ Headaches- if yes, How long do they last? ______How often? ______

Ears/Nose/Mouth/Throat:

⁭ Change in hearing ⁭Ear infections ⁭Vertigo ⁭Nasal congestion

⁭ Seasonal runny nose ⁭ Nasal bleeding ⁭ Mouth sores⁭Dentures: upper lowerboth

⁭ Hoarseness⁭ Neck masses⁭ Noisy Breathing⁭ Neck gland swelling

⁭ Pain in jaw joint (TMJ)

Cardiovascular:

⁭Chest pain ⁭ Heart palpitations⁭ Fainting-syncope⁭ Leg swelling

⁭Shortness of breath with exertion⁭ Inability to sleep on back due to difficulty breathing

Respiratory:

⁪ Shortness of breath ⁪ Wheezing/asthma⁪ Frequent cough⁪ Coughing up blood

⁭Productive Cough ⁪ Fever/night sweats ⁪Frequent respiratory infections

Gastrointestinal:

⁪ Increased appetite⁪Decreased appetite⁪ Difficulty swallowing⁪ Abdominal pain⁪ Heartburn

⁪ Nausea/Vomiting⁪ Bloating⁪ Black tarry stools ⁪Blood in the stool ⁪ Constipation

Genitourinary:

⁪ Frequent urination at night If yes, number of times per night: ______⁪Burning on urination

⁪Blood in the urine⁪loss of bladder control ⁪ decreased libido⁪ Wet the bed on occasion

⁪Men: Enlarged prostate ⁪ Difficulty starting urine stream

⁪ Women: irregular periods⁪Vaginal discharge

Hematologic/Lymphatic/Endocrine:

⁪ Swollen lymph nodes⁪Anemia (low blood count)⁪ Tendency to bleed⁪ Intolerance to heat or cold

⁪ Blood disorder⁪ Bruising

Integumentary:

⁪ New or larger pigmented spots⁪ Dry skin⁪ Rashes

Musculoskeletal:

⁪Painful joints⁪ Swollen joints: ⁪ Red ness of joints or muscles ⁪ Muscle cramps

Neurological:

⁪Frequent headaches⁪Loss of consciousness⁪ Difficulty with memory⁪ Numbness and tingling

⁪ Weakness⁪ Difficulty with coordination ⁪ Difficulty following instructions

Psychiatric:

⁪Depression: ⁪ Anxiety⁪ Hallucinations

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Not at all / Several days / More than half the days / Nearly
every day
Little or not interest in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having too little energy
Poor appetite or overeating
Feeling bad about yourself – or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed.
Or the opposite – being so fidgety or restless that you have been moving that you have been moving around a lot more than usual
Thoughts that you would be better off dead, or of hurting yourself in some way
If you checked off any of the above problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Not Difficult at allSomewhat DifficultVery DifficultExtremely Difficult
T.J. Health Partners Sleep Clinic

THE 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. 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 = no chance of dozing

1 = slight chance of dozing

2 = moderate chance of dozing

3 = high chance of dozing

SITUATIONCHANCE OF DOZING

Sitting and reading______

Watching TV______

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

As a passenger in a car for an hour without a break______

Lying down to rest in the afternoon when circumstances permit______

Sitting and talking to someone______

Sitting quietly after a lunch without alcohol______

In a car, while stopped for a few minutes in traffic______

Total______

T.J. Health Partners Sleep Clinic

SLEEP OBSERVER QUESTIONNAIRE

The sleep observer should complete this questionnaire (not the patient).

How many of the following have you observed in the patient?

(check all that apply)

While AsleepWhile Awake

____Light snoring____Morning headaches

____Moderate snoring____Morning sluggishness

____Loud snoring____Morning confusion

____Twitching/kicking of legs or feet____Excessive sleepiness

____Pauses in breathing____Fainting episodes

____Pauses in breathing with loud snorts____Napping

____Grinding teeth____Forgetfulness

____Sleep talking____Increased irritability

____Sleep walking____Falls asleep while watching TV

____Bed-wetting (on occasion)____Falls asleep in the car (as a passenger)

____Sitting up in bed but not awake____Falls asleep during conversations

____Becoming very rigid &/or shaking in bed____Falls asleep in public places

(waiting room, church, movies, etc.)

Space below is given to elaborate on any of the above or to add comments not listed above:

Form completed by:

Name relationship to patient date

T.J. Health Partners Sleep Clinic

MEDICATION LIST

Are you allergic to any medications? Y or N If yes, please list:______

Please list the medications you take on a daily basis. (Prescription and over the counter)

Please complete only the Medication name, Dose and Frequency sections.

Medication / Dose / Frequency / Date of office visit
* Patient Initial

√ = Patient is taking this medication at this dose and frequency

Χ =Patient has discontinued this medication (include date DC’ed)

→ =Patient given prescription for this medication

* =I acknowledge and understand the physician depends on the accuracy and completeness of the information I provide concerning my present medications and dosages, and they will not assume any responsibility for medications prescribed by other practitioners. Furthermore, I acknowledge I have received a copy of this form and I will consult with my attending physician if I have any questions regarding my medications.

1. Draw an arrow down () to show when you go to bed.T.J. Health Partners Sleep Clinic

2. Draw an arrow up () to show when you got out of bed

3. Draw a straight line (|) down to show when you think you fell asleep.

4. Draw a straight line (|) down to show when you think you woke

5. Shade in all the boxes that show when you are asleep.

6. Record Naps in the same way.

7. Record Meds for Sleep with an “M” at the time taken and

record which medication and dose were used beneath.

8. Record Meds for Alertness with an “A” at the times taken and

Dear Sir Or Madame

Sleep History/Medical History Questionnaire

Patient Name: ______

Current Height: ______feet ______inches

Current Height: feet inches