New Patient Questionnaire (Insurance)

Main Reason For Today's Visit*

Which one of the following symptoms are true for you? *

	Yes	No
Loud Snoring
Waking up gasping or choking from sleep
Has anyone noticed that you stopped breathing while sleeping?
Getting up from sleep to urinate multiple times at night
Lack of refreshing sleep upon waking up
Morning Headache
Dry mouth in the morning
Excessive daytime sleepiness
Difficulty falling asleep
Difficulty staying asleep
Attention or concentration problems
Memory loss
Heartburn or acid reflux
If female, decreased libido. If male, erectile dysfunction.
Feeling drowsy while driving
Have you had any motor vehicle accidents or near accidents due to drowsiness?
Any nasal sinus issues?
Seasonal Allergies
History of nasal trauma?
History of nasal fractures?
History of tonsil removal?

SLEEP REVIEW OF SYSTEM*

	YES	NO
When laughing, do you feel weak and fall to the ground?
Upon waking up, can you move arms and legs?
While falling asleep or when waking up, do you see or hear things that are not there?
Do you grind your teeth while sleeping?
Do you act out in your dreams?
Do you walk in your sleep?
Do you talk in your sleep?
Do you have urge to move legs?
Does the that urge to move legs get worse with rest?
Does that urge to move legs get worse in the evening?
Does that urge to move legs improves with exercise/stretching?
Do you still have your tonsils?

Did you have a prior sleep study?*

YesNo

If yes, where and when was the sleep study done? If you have the results, please upload a copy of your sleep study results in the file upload section below.

Have you ever had any type of treatment for sleep apnea? If yes, list names of treatment (For e.g. CPAP, BiPAP, Oral Appliance, Surgery). Did the treatment work?

Is your family history significant for any of the following?*

	YES	NO	Relation
Obstructive Sleep Apnea
Insomnia
Restless Leg Syndrome
Narcolepsy

SLEEP SCHEDULE

Time that you go to bed (Weekdays):*

Hour Minutes

AM/PM Option

Time that you wake up (Weekdays):*

Hour Minutes

AM/PM Option

Time you take to fall asleep:*

Total number of hours slept: *

Total number of hours your body requires to feel refreshed:*

Is your sleep schedule different on weekend: *

Time that you go to bed (Weekends):*

Hour Minutes

AM/PM Option

Time that you wake up (Weekends):*

Hour Minutes

AM/PM Option

Do you wake up from sleep during night?*

YesNo

How many times do you wake up every night and why? *

Do you take naps?*

YesNo

If yes how many naps, do you take per day?*

How long is each nap? *

What is your preferred sleeping position?*

e.g. Flat, side-lying, etc.

Past Medical History (Have you had or do you have any of the following conditions? Check ALL that apply):*

Surgical History: (List surgeries that you have had): blank

Allergies*

No Known Drug AllergiesYes, I am allergic to drugs.

List Allergies (if any)

Medication List: (Put name, dose and frequency of each medication you are taking. If you are not taking medication, put "None").Medication List: (Put name, dose and number of times you are taking medication. If you are not taking medication, put "None").

Do you smoke tobacco?*

YesNo

If yes, how much tobacco do you use per day and how many years have you been smoking for?

Do you drink Alcohol?*

YesNo

If yes, how much alcohol do you use per day and how many years have you been drinking alcohol for?

Do you use recreational drugs?*

YesNo

If yes, what recreational do you use per day and how many years have you been using them for?

Do you drink caffeine?*

YesNo

If yes, how much coffee do you use and when is the last time before sleep?

Do you take opioids?*

YesNo

If yes, how much coffee do you use and when is the last time before sleep?

Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations?

No chance = 0 Slight Chance = 1 Moderate Chance = 2 High Chance = 3

SITUATION*

	CHANCE OF DOZING
Sitting and Reading
Watching TV
Sitting inactive in a public place (e.g. a theater or a meeting)
As 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 a lunch without alcohol
In a car, while stopped for a few minutes in traffic

Total Epworth Sleepiness Score:*

REVIEW OF SYSTEM (CHOOSE ALL THAT APPLY)

Patient's Name*

First NameMiddle NameLast Name

Patient's Signature*

Date Signed*

Date

The section below is called Filed Upload. It is mandatory for us to receive the following before your appointment.

1. Copy of your current Govt. Issued ID card (Driver's License or Passport).

2. Copy of your primary insurance card (both front and back).

3. If applicable, copy of your secondary insurance card (both front and back)

File Upload Section for Govt. Issued ID card, Insurance card, etc. *

Medication List: (Put name, dose and number of times you are taking medication. If you are not taking medication, put "None").