Pacific Sleep Program

New Patient Questionnaire

Please correct the errors described below.

The Epworth Sleepiness Scale

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, give a general estimate for each situation.

0: NEVER doze

1: SLIGHT chance of dozing

2: MODERATE chance of dozing

3: HIGH chance of dozing



Please answer the following questions to the best of your ability:

Please list the physicians who should receive a copy of your sleep study results:

Add new row

If Yes, when and where:

Work

Sleep Patterns

Please complete the following questions about your sleep patterns as best you can. You may, if you wish, have a bed partner or family member complete this section with you.

Bed Time

Rise Time

How long it takes you to fall asleep

Typical sleep schedule on work days

Typical sleep schedule on days off

If Yes, how frequently do you nap?


Please answer the following questions by selecting the option that best fits.

If Yes, please describe:

If Yes, please answer the following questions by choosing the option that best fits:


Please answer the following questions by choosing the option that best fits

If Yes, how often?


Please answer the following questions by choosing the option that best fits:

If Yes, do you wear a night guard?

Medical History

Please check all that apply to you.

Surgical History

Please check all that apply to you.

Family History

If you didn’t check either box, please complete below.

Social History

If Yes, how many alcoholic drinks do you have during the week?

If Yes, which types and how often per week?

If Yes, how many times throughout the week?

If Yes, how many packs or cans per day and for how long?

If No, have you ever smoked?

If Yes, when did you quit?

(if you can’t remember the exact date, give your best approximation)

If Yes, how much of the following beverages do you drink?

In a usual 24-hour period

Within 6 hours of going to bed

I don’t drink this caffeinated beverage

Caffeinated coffee

Caffeinated tea

Caffeinated soda or pop

Caffeinated energy drinks

If Yes, what type of exercise and how frequently?

Medications

Please list all of your current medications and dosages, including non-prescription medications.

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If Yes, please list each medication or substance you are allergic to and explain how you react to it below:

Add new row

Thank you for completing the form. The information has been routed in a secure, HIPAA-compliant manner to Pacific Sleep Program in anticipation of your upcoming appointment.

If you have any questions, please contact us at (503) 228-4414. We look forward to seeing you at your appointment!

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