New Patient Questionnaire (Self-pay)

Main Reason For Sleep Consultation*

Which one of the following symptoms are true for you? *

Rows	Yes	No
Loud Snoring
Waking up gasping or choking from sleep
Has anyone noticed that you stopped breathing while sleeping?
Getting up from sleep to urinate multiple times at night
Lack of refreshing sleep upon waking up
Morning Headache
Dry mouth in the morning
Excessive daytime sleepiness
Difficulty falling asleep
Difficulty staying asleep
Attention or concentration problems
Memory loss
Heartburn or acid reflux
If female, decreased libido. If male, erectile dysfunction.
Feeling drowsy while driving
Have you had any motor vehicle accidents or near accidents due to drowsiness?
Any nasal sinus issues?
Seasonal Allergies
History of nasal trauma?
History of nasal fractures?

SLEEP REVIEW OF SYSTEM*

Rows	YES	NO
When laughing, do you feel weak and fall to the ground?
Upon waking up, can you move arms and legs?
While falling asleep or when waking up, do you see or hear things that are not there?
Do you grind your teeth while sleeping?
Do you act out in your dreams?
Do you walk in your sleep?
Do you talk in your sleep?
Do you have urge to move legs?
Does the that urge to move legs get worse with rest?
Does that urge to move legs get worse in the evening?
Does that urge to move legs improves with exercise/stretching?
Do you still have your tonsils?

YesNo
If yes, where and when was the sleep study done? Do you have the results?
Have you ever had any type of treatment for sleep apnea? If yes, list names of treatment (For e.g. CPAP, BiPAP, Oral Appliance, Surgery). Did the treatment work?

Is your family history significant for any of the following?*

Rows	YES	NO	Relation
Obstructive Sleep Apnea
Insomnia
Restless Leg Syndrome
Narcolepsy

Sleep Schedule:
Time that you go to bed (Weekdays):*

Hour Minutes

AM/PM Option
Time that you wake up (Weekdays):*

Hour Minutes

AM/PM Option
Time you take to fall asleep:*
Total number of hours slept:*
Total number of hours your body requires to feel refreshed:*
Is your sleep schedule different on weekend: *
Time that you go to bed (Weekends):*

Hour Minutes

AM/PM Option
Time that you wake up (Weekends):*

Hour Minutes

AM/PM Option
YesNo
How many times do you wake up every night and why? *
YesNo
If yes how many naps, do you take per day?*
How long is each nap? *
What is your preferred sleeping position? *
e.g. Flat, side-lying, etc.
AnemiaAtrial FibrillationAutoimmune DisorderAnxiety/DepressionBleeding/Clotting DisorderCancerHeart DiseaseDeep Vein ThrombosisDiabetesSleep ApneaDrugs/Alcohol AbuseThyroid DiseaseAcid reflux (GERD)Bladder/Urinary ProblemsHigh Blood PressureHyperlipidemiaKidney DiseaseVaricose VeinsStrokeTIACardiac Pacemaker/ DefibrillatorAsthmaCOPDPulmonary EmbolismRestless Leg SyndromeGlaucomaArthritisPsychiatric disorderNone of the aboveOther
Surgical History: (List surgeries that you have had): blank
Allergies: blank
Medication List: (Put name, dosage, how many times a day are you taking it). If not taking any medications, put "None
blanks blank Type a label Type a label Type a label Type a label
YesNo
If yes, how much tobacco do you use per day and how many years have you been smoking for?
YesNo
If yes, how much alcohol do you use per day and how many years have you been drinking alcohol for?
YesNo
If yes, what recreational do you use per day and how many years have you been using them for?
YesNo
If yes, how much coffee do you use and when is the last time before sleep?
YesNo
If yes, please put name of opioid, dosage, frequency and reason for taking 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	CHANCE OF DOZING
Sitting and Reading
Watching TV
Sitting inactive in a public place (e.g. a theater 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 traffic
TOTAL SCORE

FeverNightsweatsFatigueDry eyesRedness in eyesNasal fractureNasal congestionGrinding teethChest painRacing heartbeatChronic coughShortness of breathAbdominal painHeartburnJoin painJoint stiffnessAnxietyDepressionSuicidal ideationsHomicidal IdeationsHeadacheMemory lossHot flashesFrequent urinationNone of the aboveOther
Patient's Name*

First NameMiddle NameLast Name
Patient's Signature*
Date Signed*

MonthDayYear
Date
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)
File Upload Section for Govt. Issued ID card, Insurance card, etc.

Cancelof
Should be Empty:

New Patient Questionairre