SLEEP STUDY PATIENT INSTRUCTION SHEET

SLEEP STUDY PATIENT INSTRUCTION SHEET
AN OVERNIGHT SLEEP STUDY HAS BEEN SCHEDULED FOR

Month Day Year
Date
YOU SHOULD REPORT TO THE SLEEP CENTER OFFICE AT

: Hour Minutes AM/PM Option
THE ADDRESS IS

2810 W. WATERS AVE,

TAMPA, FL 33614

THE PHONE NUMBER IS 813-935-5501.

WHILE WE WILL MAKE EVERY EFFORT TO CONTACT YOU TO CONFIRM YOU SLEEP STUDY DATE AND TIME, YOU SHOULD CALL THE OFFICE AT 813-935-5501 AT LEAST 24 HOURS BEFORE YOUR SLEEP STUDY IF YOU WILL BE LATE OF IF YOU MUST CANCEL YOUR APPOINTMENT. IF YOU MISS YOUR APPOINTMENT OR FAIL TO CANCEL WITHOUT 24 HOURS NOTICE, YOU WILL BE CHARGED A $100 CANCELLATION FEE, WHICH WILL NOT BE COVERED BY YOUR INSURANCE.

BY INITIALLING I UNDERSTAND THE CANCELLATION/NO-SHOW FEE POLICY.

WE WILL CONTACT YOUR INSURANCE COMPANY TO PREAUTHORIZE YOUR SLEEP STUDY. WE URGE YOU TO ALSO CALL YOUR INSURANCE COMPANY TO VERIFY THAT YOUR SLEEP STUDY HAS BEEN PREAUTHORIZED. IF YOU HAVE ANY QUESTIONS OR CONCERNS REGARDING INSURANCE OR BILLING, OR IF YOU NEED TO MAKE FINANCIAL ARRANGEMENTS, PLEASE CONTACT THE OFFICE.

YOUR SAFETY IS IMPORTANT TO US. IF YOU ARE EXPERIENCING ANY SLEEPINESS AS A RESULT OF YOUR SLEEP PROBLEMS, PLEASE HAVE SOMEONE DRIVE YOU TO AND FROM YOUR TEST; HOWEVER, GUESTS ARE NOT PERMITTED TO SPEND THE NIGHT EXCEPT IN SPECIAL CIRCUMSTANCES WHICH HAVE BEEN APPROVED BY THE DOCTOR.

WHEN YOU ARRIVE FOR YOUR STUDY YOU WILL BE SHOWN A SHORT VIDEO, AND YOU WILL BE SHOWN ALL OF THE EQUIPMENT AND TESTING MATERIALS THAT WILL BE USED. ANY QUESTIONS WILL BE ANSWERED BY THE TECHNICIANS. TESTING ELECTRODES AND EQUIPMENT WILL THEN BE SET UP, AND YOU WILL BE ALLOWED TO RELAX PRIOR TO BEDTIME.

TESTING BEGINS AROUND 11:00 PM. THE TELEVISION AND ALL ELECTRONICS, INCLUDING CELL PHONES, MUST BE TURNED OFF AT THIS TIME.

YOU WILL BE READY TO BE DISCHARGED BY 6:00 AM THE NEXT MORNING.
ON THE DAY OF THE STUDY, PLEASE FOLLOW THESE INSTRUCTIONS
1. DO NOT TAKE ANY NAPS OF THE DAY OF YOUR STUDY.

2. DO NOT EAT OR DRINK ANY PRODUCTS CONTAINING CAFFEINE (COFFEE, TEA, CHOCOLATE)

3. EAT A REGULAR DINNER PRIOR TO COMING TO THE SLEEP LAB. YOU MAY BRING YOUR OWN SNACKS AND BEVERAGES (WITHOUT CAFFEINE) IF YOU WISH, BUT THE SLEEP LAB DOES NOT PROVIDE ANY FOOD.

4. TAKE YOUR MEDICATIONS AS YOU USUALLY DO, UNLESS THE DOCTOR HAS TOLD YOU OTHERWISE. MAKE SURE THAT YOU BRING YOUR MEDICATIONS WITH YOU, AS THE SLEEP LAB DOES NOT PROVIDE ANY MEDICATIONS.

5. DO NOT BRING ANY VALUABLES TO THE SLEEP LAB, INCLUDING LAPTOP COMPUTERS. THE SLEEP LAB DOES NOT HAVE WI-FI CAPABILITY.

6. YOUR HAIR AND SKIN SHOULD BE CLEAN AND DRY. PLEASE DO NOT USE ANY MOISTURIZERS OR OILS ON YOUR SKIN. PLEASE DO NOT USE ANY STYLING PRODUCTS (MOUSSE, GEL) IN YOUR HAIR.

7. DO NOT DRINK ANY ALCOHOL PRIOR TO YOUR SLEEP STUDY. NO ALCOHOL IS ALLOWED IN THE SLEEP CENTER.

8. INFORM THE TECHNICIAN IF YOU USE SUPPLEMENTAL OXYGEN. THE SLEEP LAB HAS OXYGEN CONCENTRATORS, IF NEEDED.
YOU SHOULD BRING THE FOLLOWING WITH YOU:
LOOSE-FITTING CLOTHING TO SLEEP IN. DO NOT BRING SLEEP CLOTHES MADE OF SILK OR SLIPPERY FABRIC. LOOSE-FITTING GYM SHORTS AND TEE SHIRTS WORK BEST.

ANY MEDICATIONS THAT YOU NEED (WE DO NOT PROVIDE ANY MEDICATION)

PILLOWS (WE PROVIDE PILLOWS BUT YOU MAY BRING YOUR OWN IF YOU WISH)

TOILETRIES (TOOTHBRUSH, TOOTHPASTE, ETC

ANY PAPERWORK THAT YOU WERE GIVEN BY THE DOCTOR A LIST OF YOUR CURRENT MEDICATIONS

IF YOU ARE ALSO HAVING A DAYTIME (MSLT) STUDY, YOU MAY ALSO BRING YOUR LUNCH FOR THE NEXT DAY. WE WILL PROVIDE BREAKFAST TO YOU.

YOU SHOULD MAKE AN APPOINTMENT TO RECEIVE THE RESULTS OF YOUR SLEEP STUDY IN APPROXIMATELY 2 WEEKS. THIS APPOINTMENT SHOULD BE SCHEDULED WITH YOUR PRIMARY CARE PROVIDER IF YOU HAVE BEEN DIRECTLY REFERRED TO THE SLEEP STUDY BUT HAVE NOT SEEN ONE OF OUR DOCTORS.
WE ARE PLEASED TO SERVE YOU AND IF YOU SHOULD HAVE ANY QUESTIONS OR CONCERNS, PLEASE CALL THE SLEEP LAB MANAGER AT 813-935-5501, EXT. 211.

PATIENT INFORMATION
Name

First Name Last Name
DATE

Month Day Year
Date
DATE OF BIRTH

Month Day Year
Date
SEX
RACE
Height
Weight
NECK SIZE
FAMILY DOCTOR
REFERRING DOCTOR
IF YOU DOCTOR DID NOT SENT YOU TO US, HOW DID YOU FIND OUT ABOUT US?

HEALTH AND FAMILY HISTORY
1. DOES ANYONE IN YOUR FAMILY HAVE A SLEEP DISORDER (ALEEP APNEA, NARCOLEPSY, RESTLESS LEG SYNDROME/PERIODIC LIMB MOVEMENT DISORDER, INSOMNIA)? IF SO, WHICH DISORDER DO THEY HAVE?
2. HAVE YOU EVER HAD A SIGNIFICANT HEAD INJURY, TIA OR STROKE?
IF SO, DESCRIBE
3. DID YOU HAVE ANY SLEEP PROBLEMS AS A CHILD?
IF SO, DESCRIBE
4. HAVE YOU FELT DEPRESSED, ANXIOUS OR WORRIED MORE THEN USUAL IN THE PAST MONTH?
IF SO, DESCRIBE

5. PLEASE LIST CURRENT HEALTH PROBLEMS THAT YOU HAVE.

	HEALTH PROBLEMS	HEALTH PROBLEMS
1
2
3
4
5
6
7

6. PLEASE LIST ANY SURGERIES.

	SURGERIES	SURGERIES
1
2
3

7. WOMEN ONLY - ARE YOU PRE OR POST MENOPAUSAL?
8. HAVE YOU ALREADY BEEN DIAGNOSED WITH A SLEEP DISORDER?
WHEN AND WHERE
9. ARE YOU ON ANY TREATMENT OR THERAPY (INCL. CPAP) NOW?
IF SO, PLEASE DESCRIBE

	YES	NO
ANXIETY, WORRY OR DISTURBING THOUGHTS
DIFFICULTY BREATHING
PAIN
SEEING/HEARING THINGS THAT DO NOT EXIST

	YES	NO
SNORING
STOP BREATHING OR GASPING FOR AIR
GRINDING YOUR TEETH
KICKING OR TWITCHING OF LEGS/FEET
ACTING OUT YOUR DREAMS
WAKING UP IN THE MIDDLE OF THE NIGHT
GOING TO THE BATHROOM EXCESSIVELY AT NIGHT
IRRITABILITY
MEMORY LOSS
DIFFICULTY CONCENTRATING
DRY MOUTH WHEN YOU WAKE UP
TOSSING AND TURNING

	0	1	2	3
Sitting and reading
Watching TV
Sitting, inactive in a public place (e.g. a theatre or a meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in the traffic

SLEEP STUDY PATIENT INSTRUCTION SHEET

ON THE DAY OF THE STUDY, PLEASE FOLLOW THESE INSTRUCTIONS

YOU SHOULD BRING THE FOLLOWING WITH YOU:

PATIENT INFORMATION

SLEEPING PROBLEMS

GENERAL HABITS

SLEEP HABITS

HEALTH AND FAMILY HISTORY

Epworth Sleepiness Scale