Mid-west center for sleep disorders
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AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION
Patient Name
Select
Male
Female
Todays Date
DOB
AGE
Race
Marital Status
Current Weight:
Weight 1 year ago:
Recent significate weight loss/gain?:
What is your main sleep related problem and duration:
SLEEP SCHEDULE (please provide the following information and circle the answer where appropriate)
What time do you go to bed on WEEKDAYS?
Hours
Minutes
AM
PM
WEEKENDS?
Hours
Minutes
AM
PM
How long does it take you to fall asleep?
What time do you wake up on WEEKDAYS?
Hours
Minutes
AM
PM
WEEKENDS?
Hours
Minutes
AM
PM
How many times do you wake up at night?
Do you nap?
Yes
No
How often do you nap?
How long are the naps?
Do you awaken refreshed?
Yes
No
Are you a shift worker?
Yes
No
If yes, what times do you work?
SNORING/ BREATHING HISTORY (please circle appropriate answer)
Do you currently use CPAP/BiPAP:(If yes, answer question based off of while using your machine)
Yes
No
If you do not use CPAP/BiPAP please continue answering the following questions.
Do you snore?
DON’T KNOW
SOMETIMES
Yes
No
Does your sleep position affect your snoring?
Yes
No
Have you awakened choking or short of breath?
Yes
No
Has anyone noticed that you stop breathing while asleep?
Yes
No
Do you have morning headaches?
Yes
No
Do you awaken more than twice to urinate during the night?
Yes
No
Do you awaken refreshed in the morning?
Yes
No
Do you awaken with an acid or sour taste in your mouth?
Yes
No
Do you have difficulty sleeping on your back?
Yes
No
Reviewed by:_
Patient Name
Reviewed By
SLEEP HISTORY (please circle appropriate answer)
Do you have difficulty falling asleep?
Yes
No
Yes
No
Do you wake up too early and cannot get back to sleep
Yes
No
Do you have thoughts racing through you mind that make it difficult to sleep?
Yes
No
Do you feel excessively sleepy during the day?
Yes
No
Have you fallen asleep unexpectedly?
Yes
No
Have you ever fallen asleep while driving drowsy?
Yes
No
Have you ever had a motor vehicular crash due to drowsy driving?
Yes
No
Have you experienced “sleep attacks” (a sudden irresistible urge to sleep?)
Yes
No
Have you experienced sudden muscle weakness in response to emotions?
Yes
No
Have you experienced an inability to move while falling asleep or waking up?
Yes
No
Have you experienced dreamlike images or sounds while falling asleep or waking up?
Yes
No
Do you kick or jerk your arms or legs during sleep?
Yes
No
Have you experienced an urge to move your legs accompanied by an uncomfortable YES NO sensation?
Yes
No
Do you have an urge to move your legs that worsens with rest or inactivity?
Yes
No
Do you have an urge to move your legs that is relieved by walking or stretching?
Yes
No
Do you have an urge to move an unpleasant sensation in legs that occurs only at night?
Yes
No
Do you talk in your sleep
Yes
No
Do you have nightmares?
Yes
No
Have you ever acted out your dreams?
Yes
No
Do you grind your teeth?
Yes
No
MEDICAL/SURGICAL HISTORY (please circle answer and fill in the blank where appropriate)
Have you ever had a sleep study in the past?
Yes
No
When?
Where?
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