Somnium Sleep: New Patient Registration & Sleep Questionnaire

Somnium Sleep Physicians

New Patient Registration & Sleep Questionnaire
Welcome to Somnium Sleep Physicians.

This form is for our new patients only. It is recommended to complete this form on a desktop or a tablet. If you using a cell phone, consider changing orientation to portrait. The form is divided into 3 parts. First part asks about patient demographics and insurance. Second part focuses on sleep history and related questions. Part three concludes with authorization and copay.
Name*

First NameLast Name
Email*
example@example.com
Cell Phone

Area CodePhone Number
Home or Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender

MaleFemaleOther
Date of Birth:

MonthDayYear
Date
Height in inches
Weight in lbs
Primary Care Provider
Leave blank if you don't have one
Referring Physician
Leave blank if none or same as primary care
Please take the front facing picture of the patient.
Please take a picture of Driver's License for verification and extra security.
There are two ways you can enter your insurance information. Either by taking a picture of the front and back of your insurance card or you may fill out the information manually.
Primary Insurance Carrier

Blue Cross Blue Shield of AlabamaMedicareMedicaidAetnaCignaUnited Health CareOther
Please take a picture of the front of your Insurance Card.
Please take a picture of the back of your insurance card.
Subscriber Name (If different from patient).

First NameLast Name
Subscriber ID #
Group Number
Effective Date

MonthDayYear
Date
Do you have a secondary insurance?

NoYesOther
Secondary Insurance Carrier (If any)

Blue Cross Blue Shield of AlabamaMedicareMedicaidAetnaCignaUnited Health CareOther
Please take a picture of the front of your Secondary Insurance Card.
Please take a picture of the back of your Secondary insurance card.
Subscriber ID #
Group Number
Effective Date

MonthDayYear
Date
Please select your concerns prompting you to see a sleep physician.

I think I may have sleep apneaI have been told I snore or do not breath normally in sleepI have trouble falling or staying asleepI am very tired or sleepy during the dayI have sleep apnea and need to establish with a new sleep physician.I am already on a CPAP & need a prescription for a new CPAP machineOther
Briefly describe the reason for your visit & what do you expect to achieve from your visit.
Please select your medical problems. Enter the box at end for conditions not listed

Diabetes Type 1 or 2Blood pressure/HypertensionCholesterolCongestive Heart FailureCoronary Artery DiseaseAsthmaCOPDInsomniaAnxietyDepressionHeartburn / RefluxLow thyroidVitamin D DeficiencyLow testosteroneSeizuresStrokeMigraine
If you have any other condition not listed above, you may add by typing it below & click "ADD MORE"
Are you allergic to any drugs/medications?

NoYes
If allergic to any medications, please list them below and the kind of reaction you have.
Medications
Please list your medications, strength, and how frequently you take it.
You can also take a picture of your medication list and upload it here.
Pharmacy
Pharmacy Name
Pharmacy Phone Number

Area CodePhone Number
Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Tobacco
Smoking status
Smokeless Tobacco
Surgeries
Have you ever had any surgeries?

NoYes
Check all that apply.

Tonsillectomy-adenoidectomyDeviated nasal septumSinus surgeryGastric Weight Loss SurgeryPalate / UPPPCABG or stentsHysterectomyOther
Family History
Any member of your immediate family with any sleep disturbance such as sleep apnea, insomnia, Restless Legs Syndrome, or sleep walking, etc?

NoYes
If positive, who and what condition do they have?
Social History
Marital Status

MarriedSingleWidowDivorcedOther
Do you live by yourself?

I live by myselfI do not live by myselfOther
Sleep alone or with someone else.

Sleep with someone else most nightsSleep by myself most nights.Other
What kind of work do you do?
Do you work night shift?

NoYes
If you do shift work, please describe your work schedule and accompanying sleep-wake times. Please also state how long have you been doing shift work.
Caffeine
Do you drink caffeine such as coffee, ice tea, soda, or energy drinks?

NoYes
What is your daily consumption of caffeine?
Generally at what time of the day is your last caffeine beverage?
Alcohol Use
Do you drink alcohol?

NoYes
How often do you drink alcohol?
Last drink of the day is around what time?
Recreational Drug Use
Do you use any recreational drug?

NoneMarijuanaCocaineOther
How often do you use recreational drugs?

RareSociallyFew times a weekRegularlyOther
Sleep Pattern
What is an approximate time you generally go to bed on weekdays or work nights?
What is an approximate time you generally go to bed on weekends or days off?
If you don't have a regular schedule, please describe your typical sleep wake schedule.
Time it takes you to fall asleep?

Instantly10 to 30 minutes30 to 60 minutes1 to 2 hours> 2 hours
Do you take or have you taken sleeping pills?

NoYes

List any other medication you have taken in the past to help with sleep and reason why you stopped taking.
Once asleep, how frequently do you wake up?

0-23-4more than 4
How often do you have trouble returning to sleep?

NeverSometimesAlways
What do you think cause your sleep to be disrupted? Select all that apply.

Not sure what wakes me upSnoring, choking or gaspingUrinationNoisesNightmaresSpouse or child(ren)PetsNeck or back PainOther
Time you generally get up in the morning on weekdays?
Time you generally get up in the morning on weekends or your days off?
How do you feel at the time you wake up?

completely restedpartially restednever restedOther
Sleep Breathing Disorder
Please select all that may apply to you. Some of these symptoms are noticed and reported by the bed partner.

SnoringChoking or gaspingBed partner noticed that you stop breathingDry mouth at the time of waking upCoughing in sleepHeartburn in sleepWaking up with a headacheOther
Disorder of Hypersomnia
Select one that would describe your level of fatigue or sleepiness.

I am not tired or sleepy during daytime.I get tired or sleepy only sometimes during the day.I am very tired or sleepy most days.I am extremely sleepy and can nod off in a heartbeat.Other
If fatigued and/or sleepy, describe how it is affecting your quality of life.
How much time do you spend driving each day?

Less than an hourMore than an hourOther
While driving, can you be sleepy or drowsy, especially journeys greater than an hour?

NeverSometimesFrequentlyOther
Have you had a motor vehicle accident due to falling asleep?

NoYes

How likely are you to doze off in following situations.*

	Unlikely "0"	Slight chance "1"	Moderate chance "2"	High chance "3"
Sitting & reading
Watching TV
Sitting, inactive in a public place (e.g. theater or a meeting)
As a PASSENGER in a car for an hour
Lying down to rest in the afternoon when circumstances permit
Sitting & talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic

Calculation
While asleep, have you ever experienced a feeling of being paralyzed or unable to move your body?

NeverOn rare occasionsSometimesFrequently
While asleep, have you ever experienced sleep hallucinations, a feeling where you see or hear things that are not there? (It is generally a different feeling from a dream or a nightmare).

NeverOn rare occasionsSometimesFrequently
While listening to a joke, something funny or when angry, have you ever experienced losing control of your knees or legs as if it has fallen asleep suddenly?

NeverOn rare occasionsSometimesFrequently
Disorders of Movement
In the evening, when you are relaxing, do you have an urge to move your legs?

NoYesOther
If yes, how would you describe that feeling.
Do you take any medicine for RLS?

NoYesOther
Please select all that apply to you.

Have been diagnosed with iron deficiency anemia or have a history of significant blood loss.A parent, sibling, or child with Restless Legs Syndrome.Noted to kick or jerk legs in sleep.
Parasomnia & Other less common conditions
Have you been told or do you think that you talk in your sleep?

NeverRarelySometimesFrequentlyOther
Have you been told or do you think that you walk in your sleep?

NeverRarelySometimesFrequentlyOther
Do you have nightmares?

NeverRarelySometimesFrequentlyOther
Are your nightmares related to PTSD (Post Traumatic Stress Disorder)?

NeverRarelySometimesFrequentlyOther
Do you have dreams in which you are defending your self or someone else because of being attacked?

NeverRarelySometimesFrequentlyOther
Have you been told or do you think that you act out your dreams?

NeverRarelySometimesFrequentlyOther
Have you been told or do you grind or clench your teeth in your sleep?

NeverRarelySometimesFrequentlyOther
Do you wear an oral appliance or bite guard for teeth grinding/clenching?

NeverRarelySometimesFrequentlyOther
Do you experience heartburn in your sleep?

NeverRarelySometimesFrequentlyOther
Do you have incontinence in your sleep?

NeverRarelySometimesFrequentlyOther

RecentLY in the last few weeks, have you experienced any? You may only select the ones that are positive.

	None	Sometimes	Frequently
Weight Gain
Weight Loss
Lack of Energy
Night Sweats
Sinus Problems
Post Nasal Drip
Mouth Sores
Facial Pain or Numbness
Loose Teeth
Ear Pain
Nosebleeds
Sore Throat
Irregular Heartbeat
Racing Heart
Chest Pain
Swelling of Feet or Legs
Shortness of breath
Night sweats
Coughing
Wheezing
Oxygen use
Asthma
COPD
Heartburn/Reflux
Constipation
Diarrhea
Abdominal Pain
Difficulty swallowing
Nausea
Vomiting
Blood in stools
Painful urination
Frequent urination
Urgency
Prostate Problems
Bladder Problems
Impotence
Joint pain
Aching muscles
Shoulder Pain
Swelling of joints
Joint deformities
Back pain
Persistent rash
Unexplained Itching
Hair loss
Frequent headaches
General weakness
Problems with walking or imbalance
Dizziness
Tremors
Loss of consciousness
Seizure or convulstion
Irritability
Depression
Anxiety
Recurring bad thoughts
Mood swings
Hallucinations
Compulsions
Suicide attempt in past or intention
Intolerance to heat or cold
Menstrual irregularities
Abnormal hunger or thirst
Changes in libido
Easy bleeding or easy bruising
Anemia
Seasonal allergies
Hay Fever symptoms
Frequent infections
Exposure to HIV

I hereby authorize Somnium Sleep Physicians to use the telehealth practice platform for telecommunication for evaluating, testing and diagnosing my medical condition.

I understand that technical difficulties may occur before or during the telehealth sessions and my appointment cannot be started or ended as intended.

I accept that the professionals can contact interactive sessions with video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met.

I understand that my current insurance may not cover the additional fees of the telehealth practices and I may be responsible for any fee that my insurance company does not cover.

I agree that my medical records on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.

You can pay copay on this part of form by entering your information. Please note, we do not store your credit card information.

USDSpecialist Copay

Credit Card

Should be Empty:

	Name	dose (mg)	How frequently?	Works good	Somewhat effective	Doesn't work
Sleeping Pill # 1
Sleeping Pill # 2
Sleeping Pill # 3
Sleeping Pill # 4

Somnium Sleep Physicians

Welcome to Somnium Sleep Physicians.

Medications

Pharmacy

Tobacco

Surgeries

Family History

Social History

Caffeine

Alcohol Use

Recreational Drug Use

Sleep Pattern

Sleep Breathing Disorder

Disorder of Hypersomnia

Disorders of Movement

Parasomnia & Other less common conditions

Credit Card