Microsoft Word - 2 - SGS Initial Patient Screening.doc



130175-15557500SLEEP GROUP SOLUTIONSInitial Patient Sleep Screening Form v. 1.0Patient Name (PRINT) Section 1: Epworth Sleepiness ScalePlease indicate how likely you are to doze off or fall asleep in the following situations:(0=never, 1=slight, 2=moderate, 3=high chance of dozing) – CIRCLE ONE RESPONSE FOR EACH QUESTIONSitting and reading……………………………………………………. 0123Watching television…………………………………………………… 0123Sitting in a public place………………………………………………..0123As a passenger in a car for one hour………………………………..0123Driving a car stopped for a few minutes in traffic………………….. 0123Sitting & talking to someone…………………………………………. 0123Sitting down quietly after lunch without alcohol…………………… 0123Lying down to rest in the afternoon…………………………………. 0123Total Score: Section 2: Patient EvaluationFill in the blanks, circle one yes or no response for each questionNo(0)Yes(1)BMI (See Attached Chart): Is it greater than or equal to 30?01Neck Circumference Is it >17” (Men) or >15”(Women)?01Have you gained at least 15lbs in the past 6 months?01Total Score: Section 3: Subjective Sleep EvaluationPlease circle one yes or no response for each questionNo(0)Yes(1)Do you snore?.01You, or your spouse, would consider your snoring louder than a person talking…. 01Your snoring occurs almost every night…01Your snoring is bothersome to your bed partner…01Do you feel that in some way your sleep is not refreshing or restful?.01Do you wake up at night or in the mornings with headaches?.01Do you experience fatigue during the day and have difficulty staying awake?.01Do you have trouble remembering things or paying attention during the day?.01Do you have high blood pressure?.01Total Score: Section 4: Prior DiagnosisNo(0)Yes(1)Have you previously been diagnosed with sleep apnea?01If Yes:When were you diagnosed? (Approx mo/yr) Were you put on CPAP Therapy for treatment? Are you still using your CPAP every night? Total Score: Notes: (Please insert any notes for the doctor regarding snoring, sleep patterns or sleep apnea that you feel may be appropriate use back of page if necessary.)Patient Signature: Date: //OFFICE USE ONLYAdvanced screening criteria, if yes to any below pt should be scheduled for advanced OSA screening. ESS Score ≥ 8? Pt. Eval ≥ 2? Subjective Sleep Eval ≥ 3? Prior OSA Diagnosis ≥ 1?OFFICE USE ONLYAdvanced screening criteria, if yes to any below pt should be scheduled for advanced OSA screening. ESS Score ≥ 8? Pt. Eval ≥ 2? Subjective Sleep Eval ≥ 3? Prior OSA Diagnosis ≥ 1?47625000SLEEP GROUP SOLUTIONSInitial Patient Sleep Screening Form v. 1.09396851278906501765597916000Watermark Medical ARES QuestionnairePRINT IN CAPITAL LETTERS – STAY WITHIN THE BOXFirst NameMiddle InitialLast NameTally ARES Risk PointsPoundsYearsGenderWeightAgeMale Female Neck Size+2 Male >16.5+2 Female>15.0FeetInchesInchesHeightNeck SizeScoreMonthDayYearOptionalDate of BirthID Number490855304165Have you been diagnosed or treated for any of the following conditions?High blood pressureYesNoStroke Heart diseaseYesNoDepressionDiabetesYesNoSleep apneaYesYes YesNoNo NoCo-morbidities+1 for each YesresponseScoreLung disease Insomnia NarcolepsySleeping MedicationYes Yes YesYesNo No NoNoNasal oxygen use Restless leg syndrome Morning HeadachesPain Medication e.g., vicodin, oxycontinYes Yes YesYesNo No NoNoDo not assign any points for these eight responses00Have you been diagnosed or treated for any of the following conditions?High blood pressureYesNoStroke Heart diseaseYesNoDepressionDiabetesYesNoSleep apneaYesYes YesNoNo NoCo-morbidities+1 for each YesresponseScoreLung disease Insomnia NarcolepsySleeping MedicationYes Yes YesYesNo No NoNoNasal oxygen use Restless leg syndrome Morning HeadachesPain Medication e.g., vicodin, oxycontinYes Yes YesYesNo No NoNoDo not assign any points for these eight responses6586220-46545500COMPLETELY FILL IN ONE CIRCLE FOR EACH QUESTION – ANSWER ALL QUESTIONSEpworth Sleepiness Scale: How likely are you to doze off or fall asleep in the following situations, inEpworth Score TOTAL the values from all 8 questions,If 11 or lessScore = 0If 12 or moreScore = 2contrast to just feeling tired? This refers to your usual way of life in recent times. Even if you have not donesome of these things recently, try to work out how they would have affected you. Use the following scale tomark the most appropriate box for each situation.(M.W. Johns, Sleep 1991)0 = would never doze1 = slight chance of dozing01232 = moderate chance of dozing3 = high chance of dozingSitting and reading Watching TV Sitting, inactive, in a public place (theater, meeting, etc) ScoreAs 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 lunch without alcoholIn a car, while stopped for a few minutes in traffic Assign points for each of the first three responsesFrequency0 - 1 times/week1 - 2 times/week3 - 4 times/week5 - 7 times/weekOn average in the past month, how often have you snored or been told that you snored?Never Rarely +1Sometimes +2Frequently +3Almost always +4Do you wake up choking or gasping?Never Rarely +1Sometimes +2Frequently +3Almost always +4Have you been told that you stop breathing in your sleep or wake up choking or gasping?Never Rarely +1Sometimes +2Frequently +3Almost always +4Do you have problems keeping your legs still at night or need to move them to feel comfortable?Never Rarely Sometimes Frequently Almost always SignatureArea CodePhone NumberTotal all 6 boxes from abovePoint TotalIf point total = 4 or 5 (low risk), 6 to 10 (high) and 11 or more (very high risk)6622415-520700007233285-520700006711950-223012000? 2009 Watermark Medical ................
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