Sleep & Airway Patient Information Form

Sleep & Airway Patient Information Form
Title

Mr.Mrs.Ms.Dr.
Name

First NameMiddle NameLast Name
Gender

MaleFemale
Status

MarriedSingleDivorcedWidowedSeparatedPartnered
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Cell Phone
Email
example@example.com
Medical insurance Card upload: Front and Back

Cancelof
Insurance
Name
Claims Address
ID
Group
Phone number
Primary subscriber
Date of Birth

MonthDayYear
Date
Medical History
Allergies

No known drug allergiesYes
If yes, list them
Medications
Patient Medical History

CancerDiabetesStrokeHypertensionObesityAIDSHeart DiseaseHeart AttackSleep DisorderThyroid DisorderUnremarkableOther
Family History

CancerDiabetesStrokeHypertensionObesityAIDSHeart DiseaseHeart AttackSleep DisorderFather SnoresMother SnoresFather has apneaMother has apneaThyroid DisorderUnremarkableOther
Surgical History (Please list any major medical surgeries)
Social History
Alcohol

Current DrinkerQuitDenies Usage
Frequency

OccasionalModerateHeavy
Type

BeerWineLiquor
Tobacco

Current every day smokerCurrent some day smokerFormer smoker
Type

CigarCigarettesSmokeless
Drug Use

CurrentFormerDenies Usage
Quit date

MonthDayYear
Date
Length of usage
Height
Weight
Signature

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East Hampton

87 Newtown Lane
East Hampton, NY 11937
(631) 856-1835
Riverhead

235 Osborn Avenue
Riverhead, NY 11901
(631) 658-5168
Should be Empty:

Insurance