Paris Registration Form
For Paris AccqSleepLabs patients, please fill out prior to sleep study once it has been booked.
1) Full Name
*
First Name
Last Name
2) Date of Birth:
Day:
*
Month:
*
Year:
*
3) Health Card # (10 numbers total):
*
VC:
*
4) Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
5) Home Phone #
*
6) Cell Phone #
*
7) E-mail Address
*
example@example.com
8) Occupation
*
9) Family Doctor
*
10) Do you have an infectious/contagious diseases? (i.e. Hepatitis A/B/C, MRSA/VRE, HIV/AIDS, Chicken Pox, Shingles, Pink Eye, Head Lice, other)
*
Yes *
No
* If yes, please specify:
11) Medical History
*
Anxiety
Arrhythmia
Arthritis
Asthma
Bipolar Disorder
Chronic Bronchitis
Chronic Obstructive Pulmonary Disease
Chronic Pain
Coronary Artery Disease
Depression
Diabetes
Emphysema
Fibromyalgia
Heart Attack
High Blood Pressure
High Cholesterol
Peripheral Vascular Disease
Schizophrenia
Stroke/ Mini Stroke
None of the Above
Other
If other:
12) Have you had a Nasal/Oral Surgery or procedure? (i.e. Tonsils removed, Deviated septum, adenoids removed)
*
Yes *
No
* If yes, please specify:
13) Is there any other medical or surgical history relevant to your Sleep Study, or that we should know about?
*
Yes *
No
* If yes, please specify:
14) Are you a smoker or a past smoker?
*
Yes *
No
* If yes, how long have you smoked?
* If yes, if you are no longer a smoker, when did you quit?
* If yes, how many cigarettes do/did you smoke per day on average?
15) Do you have any allergies?
*
Yes *
No
* If yes, please specify:
16) Please list the medications you are taking, time of day you take them and dosage (if known).
*
Please include Medication Name, Time and Dosage
Please include any other over the counter medications or supplements that you usually take.
17) What is your normal bedtime?
*
18) How long does it normally take you to fall asleep usually?
*
19) What time do you normally wake up?
*
20) Do you wake up during the night?
*
Yes *
No
* If yes, how many times?
21) Do you normally nap?
*
Yes *
No
* If yes, how many times?
* If yes, how long do you normally nap for?
22) Do you normally consume alcohol?
*
Yes *
No
* If yes, how often? How much?
23) Do you normally consume coffee?
*
Yes *
No
* If yes, how often? How much?
24) Do you normally consume tea?
*
Yes *
No
* If yes, how often? How much?
25) Do you normally consume chocolate?
*
Yes *
No
* If yes, how often? How much?
26) Do you exercise regularly?
*
Yes *
No
* If yes, how many times per week and for how long?
* If yes, what times of day?
Submit
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