• New Patient Questionnaire

    New Patient Questionnaire

  • Format: (000) 000-0000.
  • Marital Status
  • Employment status
  • May we contact you/leave a message by phone, email and text?*
  • Format: (000) 000-0000.
  • May we leave a message with a family member i.e. emergency contact?*
  • Type Of Insurance:

  • Name of Primary Insurance Policy Number:       
    Group Number:            Effective Date:   Pick a Date   

  • Name of Secondary Insurance Policy Number:        Group Number:      Effective Date:   Pick a Date   

  • Do you have MediCal/Medicaid? If yes, please do not proceed and call our office.*
  • Who referred you to us?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Primary Care Physician/Dentist Name (same as above):
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Which one of the following symptoms are true for you? *
    Rows
  • SLEEP REVIEW OF SYSTEM*
    Rows
  • Did you have a prior sleep study?*
  • Is your family history significant for any of the following?*
    Rows

  • SLEEP SCHEDULE

  • Time that you go to bed (Weekdays):*
  • Time that you wake up (Weekdays):*
  • Time that you go to bed (Weekends):*
  • Time that you wake up (Weekends):*
  • Do you wake up from sleep during night?*
  • Do you take naps?*
  • Past Medical History (Have you had or do you have any of the following conditions? Check ALL that apply):*

  • Surgical History: (List surgeries that you have had):                      

  • Allergies*

  • Medication List: (Put name, dose and frequency of each medication you are taking. If you are not taking medication, put "None").                  

  • Do you smoke tobacco?*
  • Do you drink Alcohol?*
  • Do you use recreational drugs?*
  • Do you drink caffeine?*
  • Do you take opioids?*

  • Epworth Sleepiness Scale

    How likely are you to doze off or fall asleep in the following situations?

    No chance = 0     Slight Chance = 1      Moderate Chance = 2    High Chance = 3

  • SITUATION*
    Rows
  • REVIEW OF SYSTEM (CHOOSE ALL THAT APPLY)
  • Date Signed*
     - -
    2 digit month, 2 digit day, 4 digit year

  • The section below is called Filed Upload.  It is mandatory for us to receive the following before your appointment. 

    1. Copy of your current Govt. Issued ID card (Driver's License or Passport).  

    2. Copy of your primary insurance card (both front and back). 

    3. If applicable, copy of your secondary insurance card (both front and back)

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Medication List: (Put name, dose and number of times you are taking medication. If you are not taking medication, put "None"). 

     

  • Should be Empty: