PAYSON SLEEP SERVICES, INC.

404 W. Main Street, Suite A, Payson, AZ85541 “Watching Over Your Sleep” (928) 474-5234 / Toll-free 1-888-720-5234

Fax (928) 474-5235 / Toll-free 1-888-304-5235

PATIENT INSTRUCTIONS

Your appointment is scheduled for ______at ______.

Please complete the enclosed forms and bring them with you to the sleep center. If you are unable to make it to your appointment, please call 928-474-5234 as soon as possible to let us know.

On the Day of your Study:$______estimated patient responsibility.

  • Avoid napping (if possible)$______due prior to or at time of study.
  • Avoid caffeinated drinks after 2 p.m.If paying cash, anything over the exact
  • Avoid excessive alcoholic beverage intakeamount will be credited to your account,
  • Eat regular meals; avoid overeating at evening meal nightshift cannot make change.
  • Take regular medications as usual(Exception: Any medication(s) that may cause drowsiness should not be taken until after your arrival to the sleep center, especially if you are driving.)
  • Artificial fingernails: At least one fingernail must be free of polish for accurate oxygen readings.

What to Bring to the SleepCenter:

  • A PHOTO ID MUST BE PRESENTED BEFORE ANY TESTING OCCURS!
  • Bring any & all prescription & over-the-counter medications that you may need!!!
  • Your health insurance card(s), completed registration forms, and payment due (if notified of any).
  • Loose-fitting sleepwear (such as shorts & T-shirt, nightgown, etc.)
  • Personal pillow (if desired) & personal grooming items.
  • If you are already on CPAP, please bring your mask with you.
  • Assorted snacks & beverages are available, but you may bring your own
  • Reading materials (if desired) / Note: Rooms have cable TV

Notes: Sleeping pills are allowed if you bring them with you (we cannot provide medications).

Showers are not available, but you may wash up in the sink in your room before leaving.

You will have some spots of paste in your hair, and will need to shampoo the next day.

Directions to SleepCenter:

  • We are at 404 W. Main Street, Suite A, which is right next to the Fire Station. Turn right into the first driveway west of the Fire Station. PLEASE USEBACKDOORENTRANCEAT REAR OF BUILDING.
  • Press intercom button upon arrival, and the technician will verify your name & let you in.
  • If you would like an escort or assistance from the parking lot, call upon arrival or before leaving home and we will meet you at your vehicle.

↑

N

Parking H

W

Y

Main Street 8

7

PAYSON SLEEP SERVICES, INC. 404 W. Main Street, Suite A “Watching Over Your Sleep” Payson, AZ85541

Phone (928) 474-5234 / Toll-free 1-888-720-5234

Fax (928) 474-5235 / Toll-free 1-888-304-5235

PATIENT REGISTRATION DATE:______

Name: ______

Last First MI Birthdate Age M/F

Marital Status: [] Married [] Single [] Widowed [] Divorced [] Legally Separated

Mailing Address: ______

Physical Address: ______

Best phone# where you can be reached or a message may be left for you: ______

Alternate Phone#: ______May we leave a message on this phone? [] Yes [] No

Occupation:______[] Retired [] Unemployed [] Disabled due to______

Employer Name______City, State: ______Phone: ______

Work hrs (if employed): [] Days [] Evenings [] Nights [] Rotating shifts

[] Full-time [] Part-time [] Other: ______

Local Emergency Contact: Name______Phone#______

Referring Physician:______Physician’s Phone#______

INSURANCE INFORMATION

Primary

Name of Insurance Company______

Name of Primary Cardholder______[] Self [] Spouse [] Parent [] Other______

If other than Self: Birthdate______[] Male [] Female Phone# (if different):______

Address (if different):______Occupation______

Employer Name______City, State: ______Phone: ______

Secondary

Name of Insurance Company______

Name of Primary Cardholder______[] Self [] Spouse [] Parent [] Other______

If other than Self: Birthdate______[] Male [] Female Phone# (if different):______

Address (if different):______Occupation______

Employer Name______City, State: ______Phone: ______

PAYSON SLEEP SERVICES

PEDIATRIC / ADOLESCENT QUESTIONNAIRE

Child’s Name:______Today’s Date:______

Date of Birth:______Age:_____ □ Male □ Female

Current Height:______Weight:______Grade in School:______

Name of Parent/Guardian:______Phone:______

Describe your child’s sleep problem:______

______

______

When did this problem begin? Explain:______

______

______

Child’s usual bedtime:______Child’s usual wake time:______

Number of naps per week:______Usual nap time(s):______

Does your child have trouble going to sleep? ______

Does your child wake up frequently at night? ______

Does your child wake up and have trouble going back to sleep? ______

Is your child difficult to wake in the morning? ______

Does your child feel extremely drowsy at times during the day? ______

Does your child fall asleep at school? ______

Does your child drink caffeinated beverages? Amount per day: ______

(Coke, Pepsi, Mountain Dew, Tea, Coffee)

Has your child had his/her tonsils removed? If so, what age? ______

Please check the answer that best describes your child’s behavior:

  1. Does your child snore at night?

___ Never

___ Rarely (less than once a month)

___ Occasionally (1-4 times a month)

___ Frequently (more than once a week)

___ Most nights

  1. Please describe the loudness of the snoring.

___ Does not snore

___ Faint (cannot hear unless near the child)

___ Light (can hear it, but not too loud)

___ Moderate (easy to hear, but not too loud)

___ Heavy (bothersome, cannot ignore)

  1. Do you see your child struggling to breathe during sleep?

___ Never

___ Rarely (less than once a month)

___ Occasionally (1 – 4 times a month)

___ Frequently (more than once a week)

___ Most nights

  1. How long has your child been having problems breathing at night?

___ No problems

___ Less than 3 months

___ Less than 6 months

___ Less than 1 year

___ More than 1 year

___ Since he/she was a baby

  1. Does your child sleep in any unusual position – neck hyperextended or with his/her bottom up in the air?

___ Yes ___ No

  1. Does your child have excessive movements during sleep?

___ Usually still

___ Normal movements

___ Somewhat restless

___ Extremely restless

  1. If your child is over 5 years, does he/she wet the bed?

___ Never

___ Rarely (less than once a month)

___ Occasionally (1 – 4 times a month)

___ Frequently (more than once a week)

___ Most nights

  1. Has there been any recent change in your child’s behavior, personality, or school performance? More irritable, defiant?

___ Yes___ No

  1. Has anyone in the family ever been diagnosed or treated for sleep apnea?

___ Yes___ No

  1. Does your child:

Feel sudden weakness in the knees, neck, or arms when emotional?______

Sleepwalk?______

Talk in sleep?______

Wake up screaming?______

Have very bad nightmares?______

Wake up coughing?______

Grind his/her teeth?______

Report being unable to move when falling asleep or awakening?______

See frightening images when falling asleep or awakening?______

Please list any medications your child is currently taking:

Medication / Dose / How Often / Reason for taking

Please check any conditions that your child has had or may have:

__ Frequent nasal congestion / __ Seizures / Epilepsy
__ Sinus problems/infections / __ Speech problems
__ Frequent throat infections / __ Vision problems
__ Frequent ear infections / __ Neuromuscular disorder
__ Chronic bronchitis or cough / __ Genetic disease
__ Asthma / __ Heart problem
__ Hearing problems or loss / __ Craniofacial disease or deformity
__ Frequent colds or flu / __ Head / brain injury
__ Allergies or Hay fever / __ Meningitis
__ Difficulty swallowing / __ Hyperactivity / ADHD
__ Poor or delayed growth / __ Anxiety / panic attacks
__ Excessive weight / __ Other behavioral / psychiatric disorder

Please provide details for any illness you have checked or is not listed:

______

I consent to allow Payson Sleep Services to conduct sleep testing (as explained) on my child, or on the child listed above for whom I am legal guardian.

______

Parent/Guardian Signature Date

PAYSON SLEEP SERVICES, INC.

404 W. Main Street, Suite A “Watching Over Your Sleep” Payson, AZ85541

Phone (928) 474-5234 / Toll-free 1-888-720-5234

Fax (928) 474-5235 / Toll-free 1-888-304-5235

Subject: Cancellations and “No-shows”

We have scheduled a qualified sleep technician for a 12-hour shift to attend to you during your sleep study.

We would appreciate your giving us as much notice as possible (at least 3 hours) if you cannot keep your appointment, so that we may attempt to either fill your appointment, or to cancel your technician for the night. Phone: 474-5234

Please understand that there is a high demand for sleep studies, and that they are relatively costly procedures due to the great amount of skilled labor that is involved in monitoring, scoring, interpreting, and reporting the vast quantity of data that is collected over the course of the night (about 1000 pages).

Sleep is a time for healing, so improving your sleep is a step toward better health!

AHCCCS Patients:

A very large majority of our missed appointments involve AHCCCS members.

If you miss your appointment, you may call us for another appointment.

If you also miss your 2nd appointment, then we will not be able to reschedule you.

All Other Patients (Non-AHCCCS):

If you miss your appointment and we do not hear from you, we will notify your doctor the following day. If you call us to reschedule, we may require a $50 deposit to make each new appointment for you, which will be refunded to you after your study is completed and your account has been settled. After 3 missed appointments, no further rescheduling will be done.

PAYSON SLEEP SERVICES, INC. 404 W. Main Street, Suite A, Payson, AZ85541

Phone (928) 474-5234 / Toll-free 1-888-720-5234

“Watching Over Your Sleep” Fax (928) 474-5235 / Toll-free 1-888-304-5235

What to Expect During Your Stay at our SleepCenter

Payson Sleep Services is owned and operated by a team of Registered Sleep Technologists, and is accredited by the Accreditation Commission for Healthcare.

Many people expect a sleep center to be a cold, bright, and clinical-looking place. However, our center is cozy and comfortable, more like a nice hotel than a clinic. We use only 100% cotton sheets, which are laundered with non-allergenic and perfume-free laundry products.

After you are checked into the sleep center and have changed into your sleeping clothes, your technician will spend about 30 to 45 minutes applying about two dozen painless sensors to your head and body. Some will be attached with tape, and others with a water-soluble paste. Women: You will be left with some paste residue in your hair, so plan any hair appointments accordingly. The sensors are designed to monitor your brain waves, muscle activity, breathing, oxygen levels, snoring, and heart rate, etc. Most people do not find the sensors uncomfortable, and are able to fall asleep normally. However, even if you only sleep a few hours, that is usually enough to diagnose any sleep disorder(s) that may be present. Some patients need only one night in the sleep center, while others may require a second night for complete evaluation & treatment.

During your sleep study, you will be able to turn from side to side, and get up to the bathroom at any time by simply saying out loud that you need to get up. The technician stays awake all night to monitor your sleep and make sure that you are safe, and will come in promptly when you call to attend to your comfort and well-being.

If you have difficulty driving after dark and need to come in early, please notify us ahead of time so that we can make sure someone is there to let you in when you arrive (the technician normally arrives ½ hour prior to first appointment). If someone will be picking you up in the morning, please have them arrive at 6:00 a.m. Also, if you have any questions, concerns, orspecial needs such as requiring assistance with dressing, toileting, communicating, or mobility, please call and speak with the dayshift technician prior to your study.

We look forward to your visit and will do all that we can to make your stay with us a pleasant one!