Patient Information

Name

DOB

Sex

Male Female Other

If other, please specify.

Address

City

State

Zip

Phone

Cell

Preferred

Check box if we may use this cell# for appt reminders text

Preferred Method of Contact

Phone Email Text

Nationality

African American/Black

American Indian/Alaska Native

Asian

Native Hawaiian/Pacific Islander

White

Ethnicity

Hispanic Non-Hispanic Declined

Marital Status

Single Married Divorced Widowed Separated Partnership

Primary Language

English Other

If other, please specify.

Who may we thank for referring you

Primary Care Provider

Phone

Preferred Pharmacy

Cross streets

Phone

Smoker

Yes No Prefer not to answer

Employer Status

Employed Self-Employed Retired Disabled Unemployed Student

Occupation

Employer

Employer Address

Phone

Emergency Contacts

Add new row

Insurance Information

Primary Insurance Carrier

Policy #

Group #

Policy Holder Name

Date of Birth

Policy Holder last 4 SSN

Relationship to Patient

Claims Address

City

State

Zip

Eligibility Phone

Copay Amount

Secondary Insurance Carrier

Policy #

Group #

Policy Holder Name

Date of Birth

Policy Holder last 4 SSN

Relationship to Patient

Claims Address

City

State

Zip

Eligibility Phone

Patient Medical History

Date

Patient Name

Gender

M F U

DOB

Height

Weight

Past Medical History (Please answer all questions to the best of your ability):

Tuberculosis (TB)

Yes No

Thyroid Disease

Yes No

Cancer

Yes No

Stomach Disease (ulcers, reflux)

Yes No

High blood pressure

Yes No

Intestinal Disease

Yes No

Diabetes (sugar high/low)

Yes No

Liver Disease

Yes No

Heart attack

Yes No

Seizures

Yes No

Kidney Disease

Yes No

Urinary issues

Yes No

Lung Disease

Yes No

Other

Yes No

Cancer: Specify Type

Diabetes: Specify if Sugar High or Low

If other, please specify.

Please explain all of the “YES” answers

Habits: Do you now or have ever used:

1) Tobacco (cigarettes, chew, pipes, vape, etc)

Yes No

If yes, how long?

Quit?

Yes No

2) Alcohol (beer, liquor, wine, etc)

Yes No

If yes, how long?

3) Caffeine (soda, coffee, tea, energy drinks, etc.)

Yes No

How many per day?

4) Illicit drugs (injected, inhaled, etc)

Yes No

Routinely (w/ doses)

If yes, quit?

Yes No

Yes No Total years

Sleep Questionnaire

A good sleep is important to your well-being. Since most people spend roughly 1/3 of their lives asleep, it is easy to see how the quality of sleep directly affects the quality of your life. One in 3 Americans has a sleep disorder making sleep/waking hours miserable. Many of these people suffer needlessly because they are unaware that a problem exists. Once detected, most sleep disorders can be corrected. If you have experienced any of the following symptoms in the last year, check the box YES. When referring to night, assume that this means during your sleep period.

Patient Name

Date of Birth

Section 1:

I have difficulty falling asleep.

Yes No

Thoughts race through my mind and this prevents me from sleeping.

Yes No

I feel afraid to go to sleep.

Yes No

I wake up during the night and have trouble falling back asleep.

Yes No

I worry about things and have trouble relaxing.

Yes No

I wake up earlier in the morning than I would like.

Yes No

I lie awake for 30 minutes or more before I fall asleep.

Yes No

I feel sad and depressed.

Yes No

Section 2:

I have been told that I snore.

Yes No

I have been told that I stop breathing sometimes when I sleep.

Yes No

I have been told my blood pressure is high.

Yes No

I have been told by friend/family that my personality has changed.

Yes No

I am gaining weight.

Yes No

I feel that I sweat more than I should at night.

Yes No

I have noticed my heart pounding during the night.

Yes No

I get morning headaches.

Yes No

I have trouble sleeping when I have a cold.

Yes No

I wake up suddenly some nights gasping for breath.

Yes No

I am overweight.

Yes No

I am losing my sex drive.

Yes No

I feel sleepy during the day even when I sleep through the night.

Yes No

Section 3:

I have a chronic cough.

Yes No

I have to use antacids (Tums, Alka-Seltzer, etc) at least once a week.

Yes No

I have morning hoarseness or get sore throats.

Yes No

I wake up at night coughing or wheezing.

Yes No

I wake up at night needing to catch my breath or with chest pain.

Yes No

Section 4:

I have had trouble concentrating in school/work.

Yes No

When I am angry or surprised, I feel like I’m going limp.

Yes No

I have fallen asleep while driving.

Yes No

I feel like I go around in a daze.

Yes No

I have experienced vivid dream-like scenes upon falling asleep/waking.

Yes No

I have fallen asleep during physical effort.

Yes No

I feel like I am hallucinating when I fall asleep.

Yes No

I like to cram a full day into every hour to get everything done.

Yes No

I have fallen asleep when laughing or crying.

Yes No

No matter how hard I try to stay awake, I fall asleep anyway.

Yes No

I sometimes feel like I am unable to move waking up or falling asleep.

Yes No

Section 5:

Other than when exercising, I will experience muscle tension in my legs.

Yes No

I have noticed (or others comment that parts of my body jerk.

Yes No

I have been told that I kick at night.

Yes No

I experience aching/”crawling” sensations in my legs.

Yes No

I experience leg pain during the night.

Yes No

Sometimes I can’t keep my legs still at night; I just have to move.

Yes No

I awaken with sore or achy muscles.

Yes No

Questions about your habits:

Weekday: Bedtime

Weekday: Nap

Weekday: Wakeup

Weekend: Bedtime

Weekend: Wakeup

Weekend: Nap

Work hours

Shift Work?

Yes No

Type of work

Please provide information for the following procedures:

CHEST XRAY/CT in the last year

Yes No

If yes, where?

Pulmonary Function/6 minute walk

Yes No

If yes, where?

Sleep studies (home or in lab)

Yes No

If yes, where?

Are you currently using CPAP/BIPAP?

Are you currently using CPAP/BIPAP? If yes, bring your compliance card/PAP machine to the office

Do you work with a durable medical equipment (DME) company

Family medical information

If Unknown Adopted

Parents: Mother

Parents: Father

Siblings: Sisters #

Siblings: Brothers #

Children: Daughter's #

Children: Son's #

RECORD RELEASE (HIPPA)

REQUEST FOR CARE & CONSENT

The undersigned consents to the medical care and treatment, as it may be deemed necessary or advisable in the judgment of my licensed care provider, which may include but are not limited to laboratory, x-ray examination, medical or surgical treatment or procedures, anesthesia, or other services rendered to the patient under the general and special instructions of the patient’s licensed care provider. DO SLEEP SOLUTIONS, INC has the right to refuse to see you if you refuse to sign the consent or if at any time you choose to revoke this consent.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient/designee signature

Date of Birth

ASSIGNMENT OF BENEFITS

I request the payment of authorized insurance benefits, including Medicare, if I am a Medicare beneficiary, may be made on my behalf to DO SLEEP SOLUTIONS, INC for any medical services provided to be by the organization (including in person and tele-visits). I authorize the release of any medical or other information necessary to determine these benefits or the benefits payable for related equivalent or services to the organization, the Health Care Financing Administration, my insurance carrier or other insurance carrier or other medical entity. A copy of this authorization will be sent to the Health Care Financing Administration, my Insurance company or other entity if requested. The original will be kept on file by the organization. I understand that I am financially responsible to the organization for any charges that are not covered by my health care benefits. It is my responsibility to notify the organization of any changes in my health care coverage. In some cases, exact insurance benefits cannot be determined until the insurance company receives the claim. I am responsible for the entire bill or balance of the bill as determined by the organization and/or my health care insurer if the submitted claims or any part of them are denied for payment. I understand that by signing this form I am accepting responsibility as explained above for all payment for products received.

By signing this document, I also acknowledge that I have received/been offered a copy of the organization’s Notice of Privacy Practices. This acknowledgment is required by the Health Insurance Portability and Accountability Act (HIPAA) to ensure aware of my rights.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient/designee signature

Date of Birth

Your information will be encrypted.

Patient Information

Emergency Contacts

Insurance Information

Patient Medical History

Medication Allergies/Intolerance (Reaction)

Food and Environmental Allergies (Reaction)

Prior Surgeries

Medications Taken

Sleep Questionnaire

Section 1:

Section 2:

Section 3:

Section 4:

Section 5:

Questions about your habits:

Please provide information for the following procedures:

Family medical information

RECORD RELEASE (HIPPA)

REQUEST FOR CARE & CONSENT

ASSIGNMENT OF BENEFITS