Integrative Sleep Solutions @ North Texas Institute of Neurology & Headache (NTINH)

Integrative Sleep Solutions @ North Texas Institute of Neurology & Headache (NTINH) - New Patient Packet

Please fill out the below New Patient Enrollment forms. All forms must be SUBMITTED at least two hours prior to your scheduled consultation, or your appointment will be auto-cancelled. If you have any questions or difficulty answering the questions contained herein, please do not hesitate to speak to one of our staff members for assistance. If you are filling this out outside of the clinic and have questions, please reach out to our front office staff at 972-403-8184. Thank you, and welcome to North Texas Institute of Neurology & Headache (NTINH)!
Name*

First NameLast Name
Today's Date

MonthDayYear
Date
Please provide the following information:*
Please provide your personal contact information: *

Medical Provider Care Team

Please list all other medical providers involved in your care who you would like to receive a copy of your NTINH reports / records. We will automatically send records as appropriate to your listed providers.
How did you hear about our office?*

Please provide the following information for your REFERRING PROVIDER (type "N/a" if not applicable) and PRIMARY CARE PROVIDER (type "N/a" if not applicable):*

	Referring Provider	Primary Care Provider
Name
Specialty
Office Phone #
Office Fax #

Other than the above, do you have any other medical providers with whom you would like your NTINH records shared: *

Preferred Pharmacy
Name of Preferred Pharmacy*
e.g., Walgreens, CVS, etc
Preferred Pharmacy: Phone #*

Area CodePhone Number
Preferred Pharmacy: Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Menstrual History
Last Normal Menstrual Period

MonthDayYear
Date
Do you plan to conceive?*
Are you currently pregnant?*
Are you currently breastfeeding?*

Allergies: Medication & Food
Do you have any known medication allergies?*
Please list each known MEDICATION allergy and the reaction associated with ingestion.
Do you have any known food allergies? *
Please list each known FOOD allergy and the reaction associated with ingestion.

Current Medications

Please list all medications that you currently take. Include the name, dose, and schedule (e.g., every morning, twice daily, as needed, etc) for each. Include all medications: over-the-counter, prescription, and vitamins.

Social History
Occupation*
Are you disabled?*
Relationship status?*
Do you currently smoke?*
How much do / did you smoke (per day)? *
When did you quit smoking?*

MonthDayYear
Date
Do you consume caffeine?*
Caffeine Types & Frequency*
Do you currently consume alcohol?*
Alcohol History: Quantity & Type*
Do you have a past history of emotional and / or physical abuse?*
Have you ever used or abused any of the following:*

MarijuanaCocaineHeroinSpeedNarcoticsNo, I have never used or abused any of these.Other

Family Medical History

Please provide the medical history for your biological immediate family members.
Are you adopted?*
Biological Family History*

What time do you GET INTO BED?*

:HourMinutesAM/PM Option
What time do you TURN OFF THE LIGHTS TO GO TO SLEEP?*

:HourMinutesAM/PM Option
What time do you GET OUT OF BED TO START THE DAY? *

:HourMinutesAM/PM Option
How many hours do you actually spend in bed? *
How many hours do you think you actually sleep?*
Do you have a bed partner who can observe your sleep? *
On average, how long does it take you to fall asleep at night?*
If it takes you more than 30 minutes to fall asleep, please indicate when this started?*
In approximately what month and year did the specific event occur? *
How often do you use medication and / or alcohol to help you fall asleep?*
If you use medication to fall asleep, what type(s) do you use? *
Please describe your predominant work schedule:*

How many days per week do you exercise 30 minutes or more?*
How many days per week do you nap?*
If you do nap, for how long (in hours and minutes)? *
e.g., 1 hr and 30 minutes
How often do you wake up in the middle of the night? *
On average, how many times do you wake up per night?*
If you wake up, what awakens you?*
What do you do when you are awake during the night?*
How long does it take for you to get back to sleep?
How do you feel when you wake up in the morning? *

Epworth Sleep Assessment
How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired (scale: 0-3):
- 0 = No chance of dozing
- 1 = Slight chance of dozing
- 2 = Moderate chance of dozing
- 3 = High chance of dozing
Sitting and reading*
Watching T.V.*
Sitting inactive in a public place (e.g., theater or meeting)*
Passenger in car for an hour without a break*
Lying down to rest in the afternoon when circumstances permit*
Sitting and talking with someone*
Sitting quietly after lunch without alcohol*
In car, while stopped for a few minutes in traffic*
Calculation*

Do you perceive yourself to be a good sleeper?*
How many hours do you sleep?*
Do you sleep in a bed?*
If you don't always sleep in a bed, where else do you sleep?*
Do you perform shift work?*
Do you have nightmares?*
Does your partner snore, keep odd hours, or disrupt your sleep?*
Do you have children who disrupt your sleep / sleep in your bedroom?*
Do you have pets that sleep in your bed / bedroom? *
What are your pets' names?*
Is your television on at bedtime?*
Is your television on a timer?*
Is there a cell phone in your bedroom at night?*
Do you awaken frequently to urinate?*
Are you clenching / grinding your teeth at night?*
Do you snore? *
Does your partner snore? *
Who snores louder, you or your partner?*
Are you tired all the time?*
Do you awaken with a headache?*
Are you a restless sleeper? *
Do you toss, turn, or kick?*
Have you ever been suspected of having a seizure?*
Even if you sleep through the night, do you still feel groggy in the morning?*
Have you gained weight?*
Is it difficult for you to close your top button on your shirt?*
If you wear a necklace, does it fit tighter?*
Should be Empty:

	Never	Occasionally	Daily	Seasonally
Watery / Itchy Eyes
Runny / Stuffy Nose
Itchy Nose
Seasonal Colds
Chronic Colds
Sinus Pressure / Pain
Post-Nasal Drip
Frequent Sneezing
Consistent Coughing
Asthma
Itchy Mouth / Throat Clearing
Dry, Red, or Itchy Skin
Tension / Migraine Headaches
Restless Sleep / Snoring
Daytime Fatigue

	Never	Occasionally	Daily
Over-the-counter anti-histamine
Over-the-counter nasal spray
Prescribed nasal spray
Neti pot
Headache medicine

	Frequently	Occasionally	Never	Don't Know
A sensation that you need to move your arms and/or legs in the evening or at bedtime?
Snore
Difficulty falling asleep
Difficulty staying asleep
Tired/sleepy during the day
Gasp, choke, or pause during breathing while asleep
Clench or grind your teeth during sleep
Move excessively during sleep
Nightmares
Sleepwalking
Act out your dreams
Drooling / waking with a dry mouth
Unrefreshing sleep
Morning headaches

	Yes	No	Unsure
Been diagnosed with obstructive sleep apnea?
Had an in-lab sleep study?
Had a home sleep study?
Been diagnosed with Restless Legs Syndrome or Periodic Limb Movement Disorder?
Performed a CPAP titration study?
Used a CPAP device for treatment of Obstructive Sleep Apnea?
Used a mouthguard or mandibular advancement device?

Integrative Sleep Solutions @ North Texas Institute of Neurology & Headache (NTINH) - New Patient Packet

Medical Provider Care Team

Preferred Pharmacy

Prior Medical History

Allergy Symptoms

Surgical History

Menstrual History

Allergies: Medication & Food

Current Medications

Social History

Family Medical History

Sleep Questionnaires

Sleep Medication History

Epworth Sleep Assessment