Complete Sleep Solutions | Adult Sleep Disorder Questionnaire

39755 Date St., Ste. 101
Murrieta, CA 92563
951 698 6629
www.completesleepsolutions.com

1. Sleep Disorders Questionnaire - Adult

Name :

Date :

Age :

Sex :

Handedness :
R L

Height :

Weight :

Collar Size :

Race (Circle) :

ETHNICITY :

Preferred Language :

Occupation :

Referring Physician :

Q : What is the main reason for this sleep disorders evaluation? (That is, what is your primary sleep problem?)

Q : How long has this been a problem?

Have there been sleep problems diagnosed in the past?
Yes No

What Treatment(s) were tried?	Did it help?
Weight Loss, avoid sleeping on back	Yes No
Oral Appliance	Yes No
Surgery : Throat? Nasal? Bariatric?	Yes No
Sleeping Pills	Yes No
Counseling	Yes No
CPAP/BiPAP	Yes No
Still on PAP now?	Yes No

If you are currently using PAP, please answer all the following questions based on wearing PAP (not what happens if you don’t wear it)

3. THE EPWORTH SLEEPINESS SCALE

Currently, how likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual status in recent weeks-months. If you are currently on CPAP or Oral Appliance Therapy, answer the questions based on how you feel currently under that therapy.

Use the following scale and circle the most appropriate number for the situation.

0 = Would Never Doze
1 = Slight Chance of Dozing

2 = Moderate Chance of Dozing
3 = High Chance of Dozing

Situation	Chance of Dozing
Sitting and Reading	0 1 2 3
Watching TV	0 1 2 3
Sitting, Inactive, in a public place (Theater, Meeting, etc.)	0 1 2 3
As a passenger in a car for an hour without a break	0 1 2 3
Lying down in the afternoon when circumstances permit	0 1 2 3
Sitting and talking to someone	0 1 2 3
In a car, while stopped for a few minutes in traffic	0 1 2 3
Sitting quietly after lunch without alcohol	0 1 2 3

5. NARCOLEPSY

1. Have you ever felt a sudden muscle weakness (face, neck, arms, legs) when you laughed, got angry, felt sad, surprised, or while having sex?
Yes No

2. Have you ever been unable to move your body just as you were falling asleep or waking up?
Yes No

3. Have you ever had any hallucinations or exceptionally vivid dreams just as you were falling asleep or waking up?
Yes No

10. PERSONAL HABITS, MEDICAL/SURGICAL & PSYCHOLOGICAL HISTORY

1. Do you currently have, or have you ever been diagnosed with :

High Blood Pressure	Yes No
Heart Attack	Yes No
A-fib	Yes No
Asthma	Yes No
Seizures	Yes No
Kidney Disease	Yes No
Diabetes	Yes No
Arthritis	Yes No
Parkinsons Dz	Yes No

Stroke	Yes No
Congestive Heart Failure	Yes No
GERD	Yes No
COPD/Emphysema	Yes No
Head Trauma	Yes No
Meningitis	Yes No
Hypothyroidism	Yes No
Panic/Anxiety	Yes No
Depression	Yes No

Other disorders not listed above :

Any surgeries?

11. MEDICATIONS

2. Please list below the name and dose of all medications you are taking and state how often and for what reason you are take each one.

NAME	DOSE	HOW OFTEN	REASON

Vaccinations (most recent) :

Flu Shot Pneumonia None recently Never

3. Do you use oxygen?
Yes No

Do you have a pacemaker?
Yes No

4. Do you any allergies to medications?
Yes No

5. Do you have any other allergies?
Yes No

6. Do you feel depressed?

Never

Rarely

Occasionally

Frequently

Always

If you answered "Frequently" or "Always" please fill out our BDI-II questionnaire.

7. Have you had a personality change?
Yes No

8. Have you ever seen a psychiatrist, psychologist or any type of counselor?

In the Past? Yes No

Currently? Yes No

9. Cigarette Smoking :

Currently? Yes No

In the Past? Yes No

Give an estimate of average packs of cigarettes/day and years of smoking packs/day for years

10. Do you currently use other forms of tobacco?
Yes No

Circle any that you use :

Cigars

Pipe

Chewing Tobacco

11. Please fill in chart below for caffeine containing drinks only :

Caffeinated Coffee

Caffeinated Tea

Caffeinated Soft Drinks

12. Do you smoke/consume marijuana or take any other mood-altering drugs?
Yes No

13. Do you currently drink alcohol?

Yes No

On the average, how many drinks on weekdays?

On the average, how many drinks on weekends?

13. OPTIONAL

How did you find us?

To better serve this community with information on sleep disorders and their treatments we would like to know how you heard about us: (Please Circle)

Doctor

Phone Book

Newspaper

Radio

Television

Friend or Family Member

Others

Research opportunities :

As an Accredited Sleep Center, Complete Sleep Solutions conducts clinical research studies from time to time. These studies are focused on new diagnostic and treatment approaches to sleep disorders including sleep apnea, insomnia, narcolepsy, etc.

Are you interested in learning more about such studies and possibly participating in a future clinical research study?
Yes No

Thank you for your time and cooperation filling out this questionnaire. Please be assured that all information is confidential.

Registration
(Please Print)

Talha Memon M.D
39755 Date St Ste. 101
Murrieta, CA 92563

Tel : (951) 698 - 6629
Fax : (951) 698 - 8732

Patient (Last, First, MI) :

Date :

Cell Phone :

Home Phone :

Mailing Address :

City :

ZIP :

Sex :

Male

Female

Birthdate :

Email Address :

Medical Insurance :

ID# :

Group# :

SSN :

Spouse's SSN (if used for billing) :

Secondary Medical Insurance :

ID# :

Group# :

Please list people we may discuss your Medical/Financial Record with, how they are related to you, and their Contact Information.

Insurance Assignment and Release

I Certify that I have insurance coverage with

and assign directly to Dr. Talha Memon all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance.

I authorize the use of my signature on all insurance submissions. the above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below. Medicare Authorization I request that payment of authorized Medicare benefits be made either to me or on my behalf to Dr. Talha DBA Complete Sleep Solutions for any services furnished to me by that provider. To the extent permitted by law, I authorize any holder of medical or other information about me to release to the Centers for Medicare and Medicaid Services and their agents any information needed to determine these benefits or benefits for related services.

Signature :

Print Name :

Date :

Acknowledgement of Receipt of Notice of Privacy Practices

I hereby acknowledge that I understand and/or have received and/or been offered a copy of this medical practice's Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area, and that i will be offered a copy of any amended Notice of Privacy Practices at each appointment. (Signing below means we will not release your medical records to anyone without your written consent)

Signature :

Date :

Print Name :

If not signed by patient, please indicate relation :

Insurance Card Front :

Insurance Card Back :

Driving Licence :

By electronically signing the Agreement, Patient consents to submitting this form in electronic form. Patient acknowledges that his/her electronic signature will have the same legal force and effect as a handwritten signature. Patient’s electronic signature, including date and time of signing will be stored electronically for Complete Sleep Solutions records.

Adult Sleep Disorder Questionnaire

1. Sleep Disorders Questionnaire - Adult

2. EXCESSIVE SLEEPINESS

3. THE EPWORTH SLEEPINESS SCALE

4. SNORING/SLEEP DISORDERED BREATHING

5. NARCOLEPSY

6. SLEEP SCHEDULE / HYGIENE / ENVIRONMENT

7. INSOMNIA

8. LEG MOVEMENT

9. PARASOMNIAS

10. PERSONAL HABITS, MEDICAL/SURGICAL & PSYCHOLOGICAL HISTORY

11. MEDICATIONS

12. FAMILY HISTORY

13. OPTIONAL

How did you find us?

Research opportunities :

Acknowledgement of Receipt of Notice of Privacy Practices

We see patients of all ages, including children as young as age 2.