New Clinic Visit Sleep Consultation Patient form Page 1
Smyrna Pulmonary & Sleep Associates
Dr. Prakash Patel
Dr. Vineesha Arelli
13181 Old Nashville Hwy. , Suite 150 1940 N. Jackson Street, Suite 150
Smyrna, TN 37167 Tullahoma, TN 37388
(615) 355-5105 (931) 536-4149
Fax (615) 355-5195 Fax (615) 355-5195
SLEEP MEDICINE CONSULT PATIENT HISTORY FORM
DATE: ____________
PATIENT NAME: ________________________________________ DOB: ______________
AGE: _____________ HEIGHT: _______________ WEIGHT: _______________
OCCUPATION: __________________________________________________________________
Describe your sleep problem: ________________________________________________________
__________________________________________________________________________________
How long ago did the problem begin? _________________________________________________
Please describe any previous evaluation or treatment for this problem _____________________
__________________________________________________________________________________
1. Do you snore? □ YES □ NO
If yes, □ mild □ moderate □ loud □ once or twice a week □every night
2. Has anyone told you that you stop breathing? □ YES □ NO
3. When sitting/lying down, do you have unpleasant sensations or creepy crawly sensations in your legs or an urge to move your legs? □ YES □ NO
4. Does the sensation/urge to move come on during periods of rest or inactivity? □ YES □ NO
5. Do the sensations and urge to move bother you more in the evening/night/day? □ YES □ NO
6. Does your bed partner tell you that you jerk your legs during sleep? □ YES □ NO
7. Do you have trouble falling asleep or staying asleep? □ YES □ NO
8. Average sleep hours per night _________
9. Do you work shift work, which shift________ □ YES □ NO
Page 1
SMYRNA PULMONARY AND SLEEP ASSOCIATES, PLLC
Page 2
PATIENT NAME: _______________________________________ DOB: ______________________________
-----------------------
Previous Surgery
Type of Surgery Year
□Lung _________
□Heart _________
□Other _________
□Other _________
Past Medical History
□COPD
□ASTHMA
□LUNG CANCER
□HIGH BLOOD PRESSURE
□HIGH CHOLESTEROL
□DIABETES
□HEART DISEASE
□OTHER:______________________________________________________________
Neck Size:_____________
FOR OFFICE USE
________ ENTERED DATA
________ SCANNED
Current Meds
___________________________________________________________________________________彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟_______________________________________________________________________________________________________________________________________________________________________________________________________________________________
Drug Allergy
Drug Reaction
• ________________________________
• ________________________________
• ________________________________
• ________________________________
• ________________________________
Symptoms
□FEVER, SWEATS OR CHILLS
□UNUSUAL FATIGUE
□WEIGHT LOSS MORE THAN 5 LBS
□HEADACHES
□EARACHES
□EYE IRRATION
□BLURRED OR DOUBLE VISION
□SINUS PROBLEMS
□DRY EYES OR MOUTH
□SNORING
□CHEST PAIN
□IRREGULAR OR RAPID HEART BEAT
□HEARTBURN
□DIFFICULTY SWALLOWING
□NAUSEA OR VOMITTING
□ABDOMINAL PAIN
□DIARRHEA
□CONSTIPATION
□DIFFICULT OR PAINFUL IRINATION
□FREQUENT URINATION
□SWELLING IN ANKLES
□JOIN PAIN
□FINGERS TURN WHITE
□BACK OR NECK PAIN
□AUTO ACCIDENT
□SERIOUS INJURY
□DIZZINESS OR FAINTING
□NUMBNESS OR WEAKNESS
□ANXIETY
□DEPRESSION
□OTHER___________________________
VACCINATION
□ INFLUENZA ______________________
Date last received
□ PNEUMOCOCCAL ______________________
Date last received
Social History
Current or Prior Occupation______________________________
Any animals/birds in your home: □Yes □No What type?______________
Alcohol use? □Yes □NO If yes, how much?__________________
Have you ever smoked? □Yes □NO
How many packs per day?____________
How many years?___________________
If you quit smoking, when?____________
Caffeinated drinks, how many per day? ____________________
Family History
Condition Which Relatives Affected
□ ALLERGIES _________________________
□ ASTHMA _________________________
□ LUNG DISEASE _________________________
□ HEART DISEASE _________________________
□ CANCER _________________________
□ OTHER _________________________
___________________________________________
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