Follow up Sleep Questionnaire

Somnium Sleep Physicians

Follow Up Sleep Questionnaire
Welcome to Somnium Sleep Physicians.

This form is for our follow up patients. It is recommended to complete this form on a desktop or a tablet. If you using a cell phone, consider changing orientation to portrait.
Patient Information
Name*

First NameLast Name
Email*
example@example.com
Cell phone Number

Area CodePhone Number
Home or Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender

MaleFemale
Date of Birth:

MonthDayYear
Date
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.
Height in inches
Weight in lbs
Insurance
Has there been any changes to your insurance since last visit?

NoYes
There are two ways to enter your insurance. You can take a picture of front and back of your insurance card or you can enter it 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 or Member ID
Group Number
Effective Date

MonthDayYear
Date
Do you have a secondary insurance ?

NoYes
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
Health History
Please select your concerns prompting you to see a sleep physician.

I am sleeping well, just need a follow up visitI need a prescription refill on my CPAP suppliesI need a prescription refill on medicineI am not sleeping well - having trouble falling or staying asleepI remain tired or sleepy during the dayOther
Briefly describe the reason for your visit if something else.
Have you been diagnosed with any new conditions since last visit?

NoYes
You may add by typing it below & clicking "ADD MORE"
Allergies
Any changes to your allergies since last visit?

NoYes
If there any new allergies to any medications, please list them below and the kind of reaction you had.
Medications
Has there been any changes to your medications list since last visit?

NoYes
If there are any changes to your medications, you may update your list using 1 of the three options below. You can describe the change, add your medication, or just take a picture of the list and upload it.
Please note any changes to your medications since your last visit.
You may also add your medications here.
You also have the option to 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
Any changes to your tobacco use since last visit?

NoYes
Describe your change in habits of tobacco use.
Surgeries
Have you had any new surgeries since last visit?

NoYes
Check all that apply.

Tonsillectomy-adenoidectomyDeviated nasal septumSinus surgeryweight lossPalate / UPPPCABG or stentsHysterectomyAppendicectomyJoint surgery such as knee, ankle, or footOther
Family History
Any changes in your family history since last visit?

NoYes
If positive, who and what condition do they have?
Social History
Relationship Status
Any change in your work history since last visit?

NoYes
What kind of work do you now do?
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
Any changes in your caffeine consumption?

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 any sleeping pills?

NoYes

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?

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- CPAP/BIPAP
If you have you been prescribed CPAP or BIPAP therapy:

I use my CPAP regularly without any problems & only need a refill of CPAP supplies.I use my CPAP regularly but having some problemsI use my CPAP infrequently because of problems with my CPAPI haven't been prescribed a CPAPOther
Please select all that may apply to you. Some of these symptoms are noticed and reported by the bed partner.

Machine is broken or ineffectiveMask does not fit properly or uncomfortable for regular useMask is causing skin rash or irritationI snore or reported to snore despite using CPAPI continue to breath through my mouth or mouth remains dryFrequent stuffy nose or congestionHeartburn in sleep or significant gas in AMWaking up with a headacheOther
Please provider information from your current machine(s). This information will help us retrieve data for provider to review information at the time of visit.
Serial Number. RESMED Machine, the SN is located on the label at the bottom of the back of the machine (first picture below). On PHILIPS DREAMSTATION, SN is on the bottom of the machine (Second Picture).
Please select your DME company where you get your supplies from

Neighborhood CPAPONeal- CPAP Plus on 280OxymedAccuRx on Valleydale Rd.MedsouthAerocare (AdaptHealth)Total Respiratory in HomewoodJernigan's (Fultondale)Amazon or from online storeI don't rememberOther
Has it been more than 5 years since your last study?

NoYes
Please select all applicable to you.

SnoringChoking or gaspingBed partner noticed that you stop breathingDry mouth at the time of waking upCoughing in sleepHeartburn in sleepWaking up with a headache
What was the outcome of the study?

NonconclusiveI did not had sleep apneaI was told I have sleep apnea & recommended CPAP
Are you interested in a sleep study or perhaps a home sleep study if clinically indicated?

NoYesOther
Do you want a prescription for a new CPAP Machine?

NoYes
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.
Do you drive for a living or does your work involve driving for prolonged periods of time?

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

NeverSometimesFrequently

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

	Unlikely	Slight chance	Moderate chance	High chance
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
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.
Other Review of Symptoms & Conditions

While asleep, do you experience any of the following?

	No	Yes
Heartburn
Grinding or clenching teeth
Use a bite guard for grinding or clenching
Nightmares
PTSD
Acting out dreams
Morning headaches
Sleep paralysis
Sleep hallucinations

Since last visit or in the past few weeks, have you experienced any?

	No	Yes
Weight Gain
Weight Loss
Nosebleeds
Nasal stuffiness
Difficulty breathing
Cough
Headaches
Seizure
Stroke
Blood thinner use
Chest pain
Anxiety
Depression
Thoughts of hurting self
Waking up to use restroom frequently
Low tetosterone
Impotence

Authorization and Copay
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.

We have made it convenient for you to pay your co-pay here. Please note that we do not store any credit card information.

USDSpecialist Co-pay

Credit Card

Should be Empty:

	Name	dose (mg)	Nightly or Weekly?	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.

Patient Information

Insurance

Health History

Allergies

Medications

Pharmacy

Tobacco

Surgeries

Family History

Social History

Caffeine

Alcohol Use

Recreational Drug Use

Sleep Pattern

Sleep Breathing Disorder- CPAP/BIPAP

Disorder of Hypersomnia

Disorders of Movement

Other Review of Symptoms & Conditions

Authorization and Copay

Credit Card