Sleep Eval Packet

Sleep Packet

Patient Information

First Name(Required)

Last Name(Required)

Email(Required)

Date of Birth(Required)

Social Security(Required)

Sex(Required)

Race

Other

Ethnicity

Primary Language

Primary Phone(Required)

Secondary Phone

Work

Address(Required)

Street Address Address Line 2 City State ZIP Code

Referring Physician(Required)

Phone

Primary Care Physician(Required)

Phone

Primary Insurance Information

Name of Insurance Company

Policy Number

Group Number

Are you the policy holder

Name of Policy Holder

First Last

Relationship to Patient

Date of Birth

Social Security

Phone

Address

Street Address Address Line 2 City State ZIP Code

Employer

Secondary Insurance Information

Do you have a secondary insurance policy

Name of Insurance Company

Policy Number

Group Number

Are you the policy holder

Name of Policy Holder

First Last

Relationship to Patient

Date of Birth

Social Security

Phone

Address

Street Address Address Line 2 City State ZIP Code

Employer

Work / Auto Related Injury

Is this the result of an accident

Date of Injury/Accident:

Insurance Carrier

Contact Name

First Last

Phone

Address

Street Address Address Line 2 City State ZIP Code

Claim Number

Insurance ID Number

State where injury occurred

Employer Name

Employer Address

Street Address Address Line 2 City State ZIP Code

Contact Name

First Last

Phone

Address where injury occurred

Job Title

Job Duties

Adjuster Handling Claim Name

First Last

Adjuster Handling Claim Phone

Attorney Handling Claim Name

First Last

Attorney Handling Claim Phone

Patient History

Which is your dominant hand?

Past Medical History

Past Surgery/Injury

Surgery/Injury

For What?

Date

Marital Status

Number of Children

Occupation

Education

Highest level of completion

Hobbies

Caffeine Intake

Coffee

Tea

Soda

Cups Per Day

Tobacco intake

Cigarettes

Chewing

Pipe

Former

Current

# Packs/day

# of Years

Alcohol intake

Occasionally

Rarely

Never

Amount/day

# of Years

Environmental Exposure

Heavy Metals

Toxic Fumes

Lead

Chemicals

Family Medical History

Constitutional Symptoms

Chills

Fatigue

Fever

Night Sweats

Weight Change

Eyes

Cataracts

Ears, Nose, Mouth & Throat

Headaches

Hearing Loss

Nose Bleeds

Sinus Problem

Cardiovascular

Chest Pain

Palpitations

Heart Murmur

Respiratory

Chronic Cough

Coughing up Blood

Shortness of Breath

Gastrointestinal

Blood in stool

Constipation

Diarrhea

Loss of Appetite

Nausea

Vomiting

Vomiting Blood

Women - Genitourinary

Planning Pregnancy

Post Menopause

Pregnant

Musculoskeletal

Arthritis

Birth Defect

Joint Swelling

Muscle Aches

Osteoporosis

Pain - Back

Pain - Neck

Spine Deformity

Skin

Birth Marks

Color Changes

Easy Bruising

Itching

Rashes

Neurological

Psychiatric

Anxiety

Depression

Personality Changes

Sleep Disturbances

Endogrine

Impotence

Thyroid Problems

Hematologic / Lymphatic

Anemia

Abnormal Clotting

Bleeding Disorders

Cancer

Allergic / Immunologic

Allergies

Frequent Infections

Immunodeficiency

Rheumatic Fever

Sleep Questionnaire

Describe your sleep problem

How long have you had this problem?

Do you have a CPAP machine? If so what brand and company is your machine from?

If you snore, does it prevent someone from sleeping?

Do you have restless or creepy feelings in your legs which prevent you from sleeping?

Has anyone noticed that you move your legs while asleep?

Do you toss and turn while in bed?

Do you feel sleepy while driving?

Have you ever had an accident related to sleepiness?

Does your sleepiness interfere with work or school?

Have you ever found yourself somewhere and do not know how you got there?

Have you had/have vivid dreams shortly after falling asleep at night?

Do you ever feel that you cannot move after lying down or just after you awaken?

Do you feel sudden weakness in your arms/legs when laughing or during emotional times?

Do you feel short of breath or have wheezing when you wake up?

Do you grind your teeth at night?

Do you wake up multiple times during the night?

Do you have trouble going back to sleep?

Do you wake up at night with thoughts racing through your mind?

Do you fall asleep more easily on the couch or in bed?

Are you easily awakened by noise or light?

Do you feel frustrated or tense when seeing your bed or bedroom?

Do you have job stress?

Do you find it difficult to get out of bed in the morning?

Do you sleep better away from home?

Check All That Apply

Naps

How Long

Refreshed After Nap?

Bedroom Rituals

Reading

Music

Time to Bed

Sleep onset

Prior Sleep Evaluation/Name of Physician

Prior Sleep Study/Name of Study

Prior CPAP Use/UPPP Procedure

THE EPWORTH SLEEPINESS SCALE

How likely are you to dose off or fall asleep in the following situation, in contrast to feeling tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to decide how they would have affected you. Use the following scale to choose the most appropriate number answer for each situation. 0= would NEVER doze | 1= SLIGHT chance of dozing | 2= MODERATE chance of dozing | 3= HIGH chance of dozing

Sitting and Reading

Watching TV

Sitting Inactive in a Public Place (e.g. a theater or meeting)

As a Passenger in a Car for an Hour

Lying Down to Rest in the Afternoon

Sitting and Talking to Someone

Sitting Quietly After Lunch (w/o Alcohol)

Driving a Car (if Stopped for a Few Minutes)

To ensure we are providing quality care, we need information from you and need to provide you with information about our practice policies. Below are links to our practice policies. Please click on each one to review prior to your visit. When you arrive for your appointment, you will be asked to electronically sign that you have reviewed and understand them.

Forms to be completed:

Policies to view only

Also, please complete the below “New Patient Packet” prior to arriving for your appointment. This information is important for your physician to review with you during your initial visit and if not completed, it may delay your appointment time. You do not need to print. Once you complete and click submit, our office will securely receive your responses.

To provide you with secure electronic access to our physicians and staff, Northeast Rehab utilizes a Patient Portal. You need an access code to register. Once you receive your access code, you can click here to register. Through our patient portal, you can request appointments, update your medical history, medications, and allergies, and send a note to your provider. We encourage you to sign up for the Patient Portal before your first visit.

Sleep Eval Packet

Sleep Packet

Patient Information

Primary Insurance Information

Secondary Insurance Information

Work / Auto Related Injury

Patient History

Sleep Questionnaire

THE EPWORTH SLEEPINESS SCALE

Hassle Free Appointments

* New Patients Only