New Patient Medical History Form (Pulmonary & Sleep)

Sussex Pulmonary & Endocrine Consultants, PA

Patient Name:

Age:

Date of Birth:

Reason for Visit:

Today's date:

Primary Care Provider:

Referring Provider:

Any other provider that you see on a regular basis:

History of cancer: When and where

Have you ever had allergy testing?

Please list all surgeries and procedures:

Check if you use any of the following:

Oxygen

CPAP/BIPAP

Nebulizer

If oxygen, Flow rate:

DME Company

If CPAP/BIPAP, DME Company:

Have you ever been exposed to (as a child or adult) any of the following: (Please check all that apply)?

Asbestos

Chemicals

Coal Dust

Silica

Fumes

Birds

If Chemicals, please specify:

If Birds, please specify:

Personal & Social History:

Highest Education Level: If Grade, specify:

Occupation: If Employed, where:

Do you have any Pets?

Yes No

If yes, what do you have?

Recreational Drug Use: If Former user, quit:

What drugs have you used or currently use: If other, specify:

Do you use or have used Marijuana including Medical Marijuana:

YES NO

Smoking History:

Current Smoker Former Smoker Never Smoker

How long have you been smoking?

When did you quit?

How Many years did you smoke?

Have you ever chewed tobacco?

YES NO

Family History:

Medication History:

IF YOU HAVE A LIST OF YOUR CURRENT MEDICATIONS PLEASE GIVE TO THE MEDICAL ASSISTANT. IF NOT PLEASE FILL BELOW. PLEASE INCLUDE PRESCRIPTION/OVER THE COUNTER MEDS/VITAMINS/SUPPLEMENTS

PLEASE LIST ANY INHALERS/NEBULIZER MEDICATIONS THAT YOU ARE TAKING

Please list your allergies/adverse reaction to medications:

Please fill out next two pages if you want to be evaluated for any sleep related complaints.

Please consult your spouse/bed partner when answering the following questions. Answer questions as it best describes a typical night or sleep pattern.

What sleep elated complaints do you have?

Have you ever had a sleep study before

Yes No

Where?

When?

On a typical night:

When do you go to bed?

When do you wake up?

How long does it take you to fall asleep?

How many times do you wake up during the night?

Typical length of awakening

Please circle your choice regarding the indicated problem by using following guideline

1 = Never; 2 = Almost Never; 3 = Sometimes; 4 = Almost Always; 5 = Always

Snoring

1 - Never 2 - Almost Never 3 - Sometimes 4 - Almost Always 5 - Always

Awakening others because of snoring.

1 - Never 2 - Almost Never 3 - Sometimes 4 - Almost Always 5 - Always

Awakening from sleep with choking or gasping.

1 - Never 2 - Almost Never 3 - Sometimes 4 - Almost Always 5 - Always

Gaps or pauses in breathing during sleep.

1 - Never 2 - Almost Never 3 - Sometimes 4 - Almost Always 5 - Always

Waking up with a headache in the morning.

1 - Never 2 - Almost Never 3 - Sometimes 4 - Almost Always 5 - Always

Waking up with dry mouth in the morning.

1 - Never 2 - Almost Never 3 - Sometimes 4 - Almost Always 5 - Always

Waking up with sour taste in the mouth.

1 - Never 2 - Almost Never 3 - Sometimes 4 - Almost Always 5 - Always

Feeling un-refreshed after a full night's sleep.

1 - Never 2 - Almost Never 3 - Sometimes 4 - Almost Always 5 - Always

Falling asleep in boring situations during the day.

1 - Never 2 - Almost Never 3 - Sometimes 4 - Almost Always 5 - Always

Kicking or leg twitching during night

1 - Never 2 - Almost Never 3 - Sometimes 4 - Almost Always 5 - Always

Leg discomfort prior to falling asleep

1 - Never 2 - Almost Never 3 - Sometimes 4 - Almost Always 5 - Always

Describe:

Body rocking during sleep.

1 - Never 2 - Almost Never 3 - Sometimes 4 - Almost Always 5 - Always

Head banging or rocking during sleep.

1 - Never 2 - Almost Never 3 - Sometimes 4 - Almost Always 5 - Always

Other body movements during sleep

1 - Never 2 - Almost Never 3 - Sometimes 4 - Almost Always 5 - Always

Describe:

Bedwetting

1 - Never 2 - Almost Never 3 - Sometimes 4 - Almost Always 5 - Always

Sleepwalking.

1 - Never 2 - Almost Never 3 - Sometimes 4 - Almost Always 5 - Always

Sleep talking.

1 - Never 2 - Almost Never 3 - Sometimes 4 - Almost Always 5 - Always

Nightmares or vivid dreams.

1 - Never 2 - Almost Never 3 - Sometimes 4 - Almost Always 5 - Always

Acting out dreams (shouting, punching in air etc. while sleeping).

1 - Never 2 - Almost Never 3 - Sometimes 4 - Almost Always 5 - Always

Tooth grinding or clenching.

1 - Never 2 - Almost Never 3 - Sometimes 4 - Almost Always 5 - Always

Paralysis during sleep or just prior to sleep.

1 - Never 2 - Almost Never 3 - Sometimes 4 - Almost Always 5 - Always

Sudden loss of muscle control while awake.

1 - Never 2 - Almost Never 3 - Sometimes 4 - Almost Always 5 - Always

Sudden weakness following an emotional experience.

1 - Never 2 - Almost Never 3 - Sometimes 4 - Almost Always 5 - Always

Dream during daytime naps.

1 - Never 2 - Almost Never 3 - Sometimes 4 - Almost Always 5 - Always

Difficulty falling asleep.

1 - Never 2 - Almost Never 3 - Sometimes 4 - Almost Always 5 - Always

Difficulty staying asleep (waking up in the night).

1 - Never 2 - Almost Never 3 - Sometimes 4 - Almost Always 5 - Always

Awakening early in the morning even though you do not have to.

1 - Never 2 - Almost Never 3 - Sometimes 4 - Almost Always 5 - Always

THE EPWORTH SLEEPINESS SCALE: How likely are you to doze off or fall asleep in the following situations? This refers to your usual way of life in recent times. Use the following scale to choose the appropriate number.

0 =Would never dose off 1 = Slight chance of dozing

2 = Moderate chance of dozing 3 = High chance of dozing

SITUATION:

SITTING & READING

0 - Would never dose off 1 - Slight chance of dozing 2 - Moderate chance of dozing 3 - High chance of dozing

WATCHING TV

0 - Would never dose off 1 - Slight chance of dozing 2 - Moderate chance of dozing 3 - High chance of dozing

SITTING IN PUBLIC

0 - Would never dose off 1 - Slight chance of dozing 2 - Moderate chance of dozing 3 - High chance of dozing

IN A CAR FOR AN HOUR

0 - Would never dose off 1 - Slight chance of dozing 2 - Moderate chance of dozing 3 - High chance of dozing

LYING DOWN IN THE AFTERNOON

0 - Would never dose off 1 - Slight chance of dozing 2 - Moderate chance of dozing 3 - High chance of dozing

SITTING AND TALKING TO SOMEONE

0 - Would never dose off 1 - Slight chance of dozing 2 - Moderate chance of dozing 3 - High chance of dozing

SITTING AFTER LUNCH

0 - Would never dose off 1 - Slight chance of dozing 2 - Moderate chance of dozing 3 - High chance of dozing

SITTING IN TRAFFIC (PASSENGER)

0 - Would never dose off 1 - Slight chance of dozing 2 - Moderate chance of dozing 3 - High chance of dozing

TOTAL

Have you had an accident or a near miss due to falling asleep while driving?

YES NO

Please describe the circumstances

What is your current weight?

Weight 1 yr. ago?

Weight 5 yrs. Ago?

This part of the page is intentionally left blank. Please write down anything else that you wish to discuss or any other details of your Past Medical/Surgical/Family/Social History that you want to provide.

Person providing information:

Date

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