Pre-Arrival Quesionnaire - Sutter · PDF filePre-Arrival Quesionnaire Name: ... Radio or Magazine ... How likely are you to doze off or fall asleep in the following situations,

127874-103 (07/14) sutterneuro.org
Pre-Arrival Questionnaire
Name: Date of Study:
If under 18, Parent/Guardian Name
Date of Birth: Age: Height: Weight:
Referring Physician: Phone #:
Referring Physicians Address:
Primary Physician: Phone #:
Primary Physicians Address:
Chief Compliant
I. Do you snore? Yes No is it? Soft Medium Loud
Is your sleeping partner affected? Yes No N/A
How many nights a week? 1 2 3 4 5 6 7
Do you snore all night? Yes No Dont Know
How many years have you been snoring?
II. Has anyone seen you stop breathing while asleep? Yes No Dont Know
What was the longest you stopped breathing?
How many times in one night does this happen?
Does your chest stop moving during the pauses? Yes No Dont Know
III. What is your typical sleeping position? Side Back Stomach
How many pillows?
IV. What time do you go to sleep?
What time do you get up?

Do you get up during the night? Yes No
How many times?
Do you take naps during the day? Yes No
How many / how long? /
V. Please check the appropriate letter for each question:
N = Never O = Occasionally F = Frequently C = Constantly
1. Excessive daytime sleepiness
2. Sweating when asleep
3. Restless sleep / arousals
4. Nighttime shortness of breath
5. Nighttime choking / coughing
6. Nightly muscle activity / leg kicking
7. Night paralysis (wake up and cant move)
8. Nightly reflux / heartburn
9. Morning headaches / nausea
10. Nightmares / Hallucinations
11. Sleep walking
12. Chest pain at night
13. Grind teeth at night
N
N
N
N
N
N
N
N
N
N
N
N
N
O
O
O
O
O
O
O
O
O
O
O
O
O
F
F
F
F
F
F
F
F
F
F
F
F
F
C
C
C
C
C
C
C
C
C
C
C
C
C
VI. Please include a list of your current medications:

VII. Have you ever......
...... been diagnosed with any respiratory problems? Yes No
...... had a history of abnormal ear/ nose/ throat structure? Yes No
...... had oral surgery? Yes No
...... had neurological testing? Yes No
...... had neurosurgery? Yes No
...... been diagnosed with depression or anxiety? Yes No
...... been diagnosed with heart problems? Yes No
If so, please explain
...... been diagnosed with blood pressure problems? Yes No
Is it controlled with medication? Yes No
...... been diagnosed with sleep apnea? Yes No
When / Where? /
Was treatment prescribed? Yes No
Any changes since diagnosis? Yes No
If you are a current CPAP user call 2-3 days prior to study: (916) 887-4001
VIII. Learning/Development Problems (pediatric patients only): (N/A Non-applicable)
A. Delayed Development Yes No N/A
B. Speech Problems Yes No N/A
C. Poor School Performance Yes No N/A

D. Special School Yes No N/A
E. Poor appetite Yes No N/A
F. Frequent nausea/vomiting Yes No N/A
G. Difficulty swallowing Yes No N/A
H. Constant nose running Yes No N/A
I. Recurrent middle ear disease Yes No N/A
J. Hearing problem Yes No N/A
K. Mouth breathes when awake Yes No N/A
L. Frequent respiratory infections Yes No N/A
M. History of pneumonia Yes No N/A
IX. Do you ......
...... feel theres been a loss of concentration or memory recently? Yes No
...... feel any personality changes? Yes No
...... have any allergies? Yes No
...... smoke? Yes No
How much?
...... drink alcohol? Yes No
How much?
...... drink caffeinated beverages? Yes No
How much?
X. What is your type of work?

XI. What motivated you to get a sleep study? (check all that apply)
Television, Radio or Magazine
Physician or Dentist
Employer
Do you have any other medical issues?
If so, please explain:
Health Literature or Presentation
Spouse or Friend
Other:
Yes No

Epworth Sleepiness Scale
Name:
Date:
Age (Yrs): Gender: 9 Male 9 Female
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times.
Use the following scale to choose the most appropriate number for each situation:
0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing
It is important that you answer each question as best you can.
Situation Sitting and reading
Watching TV
Sitting, inactive in public place (e.g. a theater or a meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic
Chance
of
Dozing
THANK YOU FOR YOUR COOPERATION
M.W. Johns 1990-97
http:sutterneuro.org

Pre-Sleep Questionnaire
Name: Date of Study:
Date of Birth: Age: Height: Weight:
1. General Functioning last night (bad) (very good)
Quality of Sleep 9 1 9 2 9 3 9 4 9 5 Daytime Energy 9 1 9 2 9 3 9 4 9 5 Ability Staying Awake 9 1 9 2 9 3 9 4 9 5 Job Performance 9 1 9 2 9 3 9 4 9 5
2. What time did you wake up today?
3. Did you get your normal amount of sleep last night? 9 Yes 9 No
4. Did you have any caffeinated or alcoholic beverages today? 9 Yes 9 No
5. Have you taken your medications today? 9 Yes 9 No
6. Substance use in the last 24 hours/ Tranquilizers 9 Yes 9 No Marijuana 9 Yes 9 No Opiates (codeine, MS, heroin) 9 Yes 9 No Alcohol 9 Yes 9 No Amphetamines (cocaine, crack, diet pills) 9 Yes 9 No Tobacco 9 Yes 9 No Hallucinogens (PCP, LSD) 9 Yes 9 No Other:
7. Did you do any exercising today? 9 Yes 9 No
8. Have you recently gained weight without trying? 9 Yes 9 No
9. When did you eat your last meal?
10. Any physical complaints today? 9 Yes 9 No
11. Are you in pain right now? 9 Yes 9 No If yes, what is the intensity? 0 10
12. Are you currently a victim of domestic violence? 9 Yes 9 No
127874-108 (07/14)

We will automatically provide the results of your study to the physician that referred you for the test. If there are any other physicians that you would like to receive a copy of your sleep study, please list them here:
Patient Name: Date of Birth:
PRIMARY CARE PHYSICIAN
Name:
Phone #:
Fax #:
EAR, NOSE, & THROAT
Name:
Phone #:
Fax #:
PULMONOLOGIST
Name:
Phone #:
Fax #:
CARDIOLOGIST
Name:
Phone #:
Fax #:
OTHER
Name:
Phone #:
Fax #:
http:sutterneuro.org
Pre-Arrival Questionnaire
If under 18 ParentGuardian Name: Referring Physician: Referring Physicians Address: Primary Physician: Primary Physicians Address: Chief Compliant: fill_15: fill_16: fill_17: fill_18: fill_19: fill_20: fill_1: fill_2: fill_3: 1: 2: 3: 4: 1_2: 2_2: 3_2: 4_2: If so please explain: When Where: undefined: If so please explain_2: If so please explain_3: fill_2_2: fill_3_2: fill_4: X What is your type of work: Group1: Check Box1: Check Box1a: Check Box1b: Check Box1c: Check Box1d: Group2: Group3: Group4: Group5: Group6: Group7: Group8: Group11: Group12: Group13: Group14: Group15: Group16: Group17: Group18: Group19: Group20: Group21: Group22: Group23: Group9: Group10: Group24: Group25: Group26: Group27: Group28: Group29: Group30: Group31: Group32: Group33: Group34: Group35: Group36: Group37: Group38: Group55: Group39: Group40: Group41: Group42: Group43: Group44: Group45: Group46: Group47: Group48: Group49: Group50: Group51: Group52: Group53: Group54: Please explain other medical issues: PRINT: SAVE AS: RESET: Name: Date: Age Yrs: Dozing 1: Dozing 2: Dozing 3: Dozing 4: Dozing 5: Dozing 6: Dozing 7: Dozing 8: Date of Study: Date of Birth: Age: Height: Weight: What time did you wake up today: Other: When did you eat your last meal: 0 10: Patient Name: Phone: Fax: Name_2: Phone_2: Fax_2: Name_3: Phone_3: Fax_3: Name_4: Phone_4: Fax_4: Name_5: Phone_5: Fax_5:

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Pre-Arrival Quesionnaire - Sutter · PDF filePre-Arrival Quesionnaire Name: ... Radio or Magazine ... How likely are you to doze off or fall asleep in the following situations,