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Adult Sleep Medicine Intake Form Name:____________________________________________Date of Birth:__________________________Please complete this form to provide valuable information in advance of your appointment. This information allows for more time to be spent in discussion, counseling on treatment options and coordination of care. If there is a specific question that you prefer to discuss in person rather than complete on the form please note it with a star and write “discuss in person”. What is(are) the reason(s) you are scheduled for an appointment?________________________________________________________________________________________________________________________________________________________________________Symptoms:Please review and answer each of the items below. For the items with a box to the left, mark the box according to what you experience. Place an “N” for never having experienced it, a “P” for having experienced it in the past and a “C” for currently experiencing it. You can place a star next to ones that are most significant. N = neverP = PastC = Currentsnoringpauses in breathing observed by someone elsewaking up with a gasp waking up chokingdaytime sleepinesswaking up early than you wantlow energy during the dayfalling asleep unintentionally during the day poor attention, concentration and focusmakes errors in your workdissatisfied with your sleepuncomfortable urge to move your legsurge to move the legs is worse at rest/inactivityurge to move the legs is worse in the evening or night compared to the morning leg crampslow iron levelssudden loss of muscle strength and falling to the ground but staying alert/awakesleep medication at bedtimefatiguenight sweatsunintentional weight gainanxietybehavioral disorderconcentration difficultiesdepressionirritabilitymemory difficultiesdry eyesdry airwaysfrequent bloody noseheadachesnasal congestionunable to breathe through the noseseasonal or environmental allergiesswollen lymph nodes hot flashescoughshortness of breathwheezingirregular heartbeatheartburnneeding to get up and urinate or wetting the bed at nightjoint painmuscle weakness confusionspeech problemstremorsdry skinhair changesDo you have a bedtime routine? Yes / NoWhen do you start your bedtime routine and what does it consist of?_________________________________________When do you get into bed? ______________________When do you try to fall asleep?_____________________How long does it take to fall asleep?___________________Do you wake up through the night?______________How often and for how long each time?________________What time do you wake up?___________________What time do you get out of bed?________________Do you take naps?_____________________If so how often and for how long?___________________Do you feel rested from your sleep?_________________What is your sleeping environment like?__________________________________________________________Do you share a bed with anyone when you sleep? Yes / NoDo you currently take any sleep aid medication or supplement and if so what? Yes / No __________________What sleep medications/supplements have you taken in the past?__________________________________________________________________________________________What position do you sleep in (back, side, stomach, move around, etc?Do you dream when you sleep? Yes / NoAre the dreams unpleasant? Yes / NoDo you have any sleep behaviors like talking or walking in your sleep?_________________________________Do you have to urinate through the night sleep period?______________________________________Do you have hallucinations as you fall asleep or wake up?___________________________________Do you have caffeine during the day? Yes / NoEpworth Sleepiness Scale:For each item state if you would never fall asleep in the situation, have a low change, medium change or high chance of falling asleep in the situation (never (0), low (1), medium (2), high chance (3)). Sitting & reading: Watching T.V.: Sitting inactive in a public place (i.e. theater): As a car passenger for an hour without a break: Lying down to rest in the afternoon: Sitting and talking to someone: Sitting quietly after lunch without alcohol: In a car, while stopping for a few minutes in traffic: Current Medications: List all medications, supplements, herbals, over-the-counter medications, treatments. Current MedicationsPrescribed MedicationsSizeDoseFrequencyPrescriber/Side EffectsLipitor(example)40mg1 tabletOnce a dayDr. Med Hills/drowsinessPast Medications:List all past medications you have used related to sleep. It is helpful if you can include information on when it was used, for how long, the dose, side effects, if it worked or not and why it was stopped.Past Sleep MedicationsPrescribed MedicationsSizeDoseFrequencyPrescriber/Side EffectsLipitor(example)40mg1 tabletOnce a dayDr. Med Hills/drowsinessFamily Sleep Health History: Do you know your biological family's sleep health history? Yes / No Please note what sleep health conditions exist in your biological family including insomnia, obstructive sleep apnea, restless legs syndrome, poor sleeper, etc. ________________________________________________________________________________________________________________________________________________________________________Social History:Social History:Do you believe in God? Yes / NoDo you have a specific religion? Yes / NoDo you attend a church? Yes / NoSocial HistoryWork?Job description: Company or place of work:Marital StatusSingle Divorced WidowedMarried Separated RemarriedWhat is your spouse’s name? (if applicable)Who do you live with?Children’s NamesDo you have any pets? Yes / NoDo you have a gun(s) where you live? Yes / NoMedical History: Please circle current and past medical conditions. Past Medical HistoryHave you been treated for any of the following conditions? Please circle all that apply.CardiovascularLung / ENTBowel/ UrologyBrain/ Nerve/ EyeMusculoskeletalEndocrine/ SkinCancer/ BloodHeart attackHeart failureAtrial fibrillationPalpitationsValve diseaseHeart murmurHypertensionCarotid diseasePVDPassing outCOPDEmphysemaAsthmaSleep apneaPneumoniaLung clot (PE)Positive PPDTMD/ TMJRinging earsAllergiesPancreatitisLiver diseaseReflux/ GERDUlcersColon diseaseColon polypsHemorrhoidsKidney diseaseBladder diseaseLarge prostateChronic headacheStroke/ TIASeizuresMemory lossNeuropathyHerniated discMacular diseaseRetinopathyCataractsGlaucomaMigrains19ArthritisFibromyalgiaGoutOsteoporosisBursitisBack painKnee painShoulder painHip painFoot problemsHigh cholesterolDiabetesThyroid diseaseLow testosteroneMenopauseAcnePsoriasisEczemaSkin cancerHair/ nail diseaseProstate CABreast CACervical CAColon CAAnemiaBleeding disorderDVT/ blood clotTransfusionHepatitis B or CHIVDo you have any of the following? Mood disorder like depression or bipolar: Hx of having the tonsils and/or adenoids removed: Breathing problems: Heart problems: High blood pressure: Diabetes:History of traumatic brain injury: Loss of consciousness: Seizures: Surgical History: Surgery/Procedure HistoryHave you had any of the following procedures (please circle)? If you can recall, add date.TonsillectomyAdenoidectomyCholecystectomyAppendectomyBowel surgeryWeight loss surgeryCarpal tunnel surgeryHip surgeryKnee surgeryShoulder surgeryFoot surgeryPlastic surgeryBreast BiopsyVasectomyProstate surgeryC SectionHysterectomyTubal ligationCystoscopyCardiac catheterizationStress testBypass surgeryStent placementPacemakerNeurosurgeryBack surgeryCataract surgeryIf so provide the details of date, reasons, outcome, etc. ________________________________________________________________________________________________________________________________________________________________________ ................
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