Questionnaire PATIENT DEMOGRAPHICSBring the printed materials for office visit or you could fax it to 989-793-7113 or 989-792-1792 Who is the Physician that referred you to us?*Who is the primary care Physician?*Do you want this report sent to another Physician?PERSONAL INFORMATIONName* First Middle Initial Last SexMaleFemaleDate of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AgeEmail Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Cell Phone*Home PhoneWork PhonePlace of EmploymentOccupation:Weight*Height*Height (inches)*BMIEMERGENCY CONTACT PERSONName*RelationshipCell Phone*Home PhonePHARMACY*Pharmacy Location*INSURANCE INFORMATIONPrimary Insurance Name*Policy#Secondary Insurance NamePolicy#(Complete only if you are not the Insurance Policy Holder)Policy Holder Name First Middle Initial Last RelationshipPolicy Holder’s Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Policy Holder’s Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip AUTHORIZATION I authorize the release of any medical information necessary to process my insurance claim, and authorize payment of medical benefits to the Facility and providers for services rendered. I am aware that payment of insurance copay/deductible is the patient’s responsibility. If necessary, I also authorize release of medical information to durable medical equipment providers and referring/primary care providers involved in my care. I authorize the use of audio and video monitoring as part of my sleep study. I understand that the copay / deductible is my responsibility. I am also aware that the Sound aSleep Sleep Diagnostic Lab facility is owned and operated by Narendra R. Kumar, M.D., P.C.* I authorize and agree by checking this box and typing my name below Your Name*Date*Do you or have you been told that you….Do you snore / have been told you snore*YesNoHold your breath or stop breathing during sleep?*YesNoHave difficulty sleeping on your back or trouble breathing while lying flat?*YesNoHave daytime sleepiness / fatigue?*YesNoHaving achy or restless legs?*YesNoWake up gasping and/or choking?*YesNoHave an itching or crawling sensation in your legs?*YesNoUnable to fall asleep due to "restless legs"?*YesNoTake naps?*YesNoAt times, have to struggle to stay awake?*YesNoHave a problem with your performance at work due to sleepiness / fatigue?*YesNoWake up with morning headaches?*YesNoHave restless sleep?*YesNoDo you toss and turn in bed?*YesNoWalk in your sleep?*YesNoTalk in your sleep?*YesNoGrind your teeth?*YesNoWet the bed (as an adult)?*YesNoDisturb the sleep of your bed partner?*YesNoHave disturbed sleep due to bed partner?*YesNoAwaken from sleep due to screaming or violence?*YesNoHave heartburn or gas during the night?*YesNoWake up with a burning sensation in your throat?*YesNoSweat excessively during sleep?*YesNoEat during the night without being aware you do so?*YesNoHave a persistent cough at night?*YesNoHave frequent need to urinate while sleeping (more than twice)?*YesNoHave nasal congestion?*YesNoHow often do you…Take naps?*NeverSometimesAlwaysFeel refreshed after you nap?*NeverSometimesAlwaysExperience dream-like images while falling asleep?*NeverSometimesAlwaysHave episodes of muscular weakness when laughing, angry, or any extreme emotional situation?*NeverSometimesAlwaysEver feel paralyzed when waking up?*NeverSometimesAlwaysExcessively sleepy during normal wake hours?*NeverSometimesAlwaysFeel refreshed upon waking up?*NeverSometimesAlwaysHow many times have you had a near auto accident (driving off the shoulder of the road) due to sleepiness?*How many times during the night do you wake up?*Have you previously been tested for a sleep disorder?*YesNoIf yes, please list: Whenand WhereAre you being treated for this condition?YesNoHave you ever used CPAP/BiPAP?*YesNoIf yes, since which year?Are you currently using CPAP/BiPAP?*YesNoAgency/ DME Name where you get CPAP/ Mask & Other SuppliesAgency NameLocationAgency/ DME Name where you get CPAP/ Mask & Other Supplies Don't Know Are you currently using oxygen?*YesNoAgency/ DME Name where you get Oxygen & other SuppliesAgency NameLocationAgency/ DME Name where you get Oxygen & other Supplies Don't Know Have you had your tonsils or adenoids removed or palatoplasty (surgical procedure) for sleep apnea?*YesNoAre you or have you ever been treated for the following:Diabetes*YesNoHigh Blood Pressure*YesNoHeart Disease (heart failure/A-FIB/heart attack/palpitation/irregular heart)?*YesNoPlease specifyDo you have a pacemaker / defibrillator?*YesNoCOPD / Emphysema / Asthma?*YesNoPlease specifyDo you use oxygen at home (Day / Night)?*YesNoHeart burn / Reflux / Hiatal hernia*YesNoDaytime Sleepiness*YesNoHypothyroidism*YesNoChronic Back / Neck or Hip pain?*YesNoADD/ADHD?*YesNoDifficulty concentrating/focusing?*YesNoDepression/Anxiety/PTSD*YesNoPlease specifyInsomnia*YesNoNeurological condition (Stroke /MS/ Parkinson’s/TIA/Memory Loss/Seizure)*YesNoPlease specifyMuscular skeletal disorders (Fibromyalgia / Muscle weakness)*YesNoPlease specifyRheumatism, Rheumatoid Arthritis, Lupus, or Osteoarthritis*YesNoPlease specifySleep related eating disorders?*YesNoKidney Disease/Failure*YesNoPlease list any other pertinent medical conditions you are currently being treated for.Which shift are you currently working?*FirstSecondThirdSwingDo you drink alcohol in excess?*YesNoDo you smoke?*YesNoPacks per dayQuit dateYou have trouble falling asleep at night*YesNoYou have trouble staying asleep once you fall asleep*YesNoDo you have trouble falling back to sleep?*YesNoPlease list any medications you are currently taking, including any medications that you have taken in the past 3 months. Please be sure to specify the dosage and the time of day you take them. Click the + button to add each medication. (**unless otherwise instructed by the physician that ordered your sleep study, continue to take all medications as usual.)MEDICATION LIST & DOSAGE Are you allergic to any medications?*YesNoIf yes, please list:Have you ever taken a prescription medication to help you fall or stay asleep?YesNoIf yes, what and when? EPWORTH SLEEPINESS SCALE(Consider at the worse time of the day and in worse situation. This is required to get pre-authorization for your sleep study)In contrast to just feeling tired, how likely are you to doze off or fall asleep in the following situations? Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation. 0 = WOULD NEVER DOSE 1 = SLIGHT CHANCE OF DOZING 2 = MODERATE CHANCE OF DOZING 3 = HIGH CHANCE OF DOZINGSitting and Reading*0123Watching TV*0123Sitting inactive in a public place (i.e., in a theatre)*0123As a car passenger for an hour without a break*0123Lying down to rest in the afternoon*0123Sitting and talking to someone*0123Sitting quietly after lunch (without alcohol)*0123In a car, while stopping for a few minutes in traffic*0123TotalSTOP-BANG QuestionnaireDo you snore loudly?*YesNoDo you often feel tired, fatigued or sleepy?*YesNoHave you been observed to stop breathing during sleep?*YesNoDo you have high blood pressure?*YesNoBMI – (Weight/height Index) over 35? BMI Calculator*YesNoAre you over 50 years of age?*YesNoIs your collar size over 16 inches for male, or 14 inches for female?*YesNoAre you a male patient?*YesNoCheck the box belowPhoneThis field is for validation purposes and should be left unchanged. Save and Continue Later Please bring the printed materials for office visit or you can fax it to 989-793-7113 or 989-792-1792.