New Patient Questionnaire
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:
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.
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?
Please check all that apply to you.
If you didn’t check either box, please complete below.
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 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 soda or pop
Caffeinated energy drinks
If Yes, what type of exercise and how frequently?
Please list all of your current medications and dosages, including non-prescription medications.
If Yes, please list each medication or substance you are allergic to and explain how you react to it below:
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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