520 North Elam Ave- Greensboro, NC 27403
Sleep Consultation Form
Name _______________________________________ DOB: ______________ Age: ________ Date: _________
Consult Requested by Dr. ____________________________________________ Self-Referred: Yes / No
HISTORY OF PRESENT ILLNESS:
Briefly describe your sleep problem: _________________________________________________
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What time do you typically go to bed? (between what hours) ______________________
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How long does it take you to fall asleep? ___________________________________
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How many times during the night do you wake up? __________________________________________ _____
What time do you get out of bed to start your day? __________________________________________ ______
Do you drive or operate heavy machinery in your occupation? _________________________________________
How much has your weight changed (up or down) over the past two years? (in pounds) _________________ ___
Have you ever has a sleep study done before? If yes, when and where? _________________________________
Do you currently use a CPAP? If so, at what pressure __________________________________________ ______
Do you wear oxygen at any time? If yes, how many liters per minute __________________________________ _
Past Medical History
CHECK CURRENT OR PAST PROBLEMS
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High Blood Pressure
Heart Attack
Angina
Heart Failure
Heart Rhythm Problems
Asthma
Emphysema
Diabetes
High Cholesterol
Stroke
Blood Clots
Cancer
Allergy or Sinus Trouble
Chronic Headaches
HIV
Kidney Disease/Failure
Sleep Apnea
Disorder of the Nervous System
CHECK PRIOR SURGERIES/APPROXIMATE
DATE
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Splenectomy _______
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Gallbladder____________
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Lung Surgery _________
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Neck/Back Surgery ________
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Colon Surgery _________
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Sinus Surgery ______
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Heart Valve _______
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Heart Bypass________
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Angioplasty/ Stent ________
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Hysterectomy ______
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Tubal Ligation _______
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Breast _________
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Appendix _______
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Organ Transplant ________
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HAVE YOU EVER BEEN EXPOSED TO:
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Tuberculosis
LIST ALL OTHER PROBLEMS/SURGERIES:
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MEDICATION ALLERGIES/REACTION:___ ______________________
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Latex Allergy? Yes / No
IV Contrast or Iodine Allergy? Yes / No
Aspirin Intolerant? Yes / No
Have you ever taken Prednisone? Yes / No
If yes, when was your last dose? _____________
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SOCIAL HISTORY:
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PLEASE CIRCLE:
I smoke How much? ___________ _ (ppd)
I quit smoking When? _____________
I use smokeless Tobacco
I drink Alcohol How much? ________
I Quit Drinking What? __________ __
I use drugs What type? ___________
I quit using drugs When? ________ __
At risk for HIV
I am: Single
Married
Divorced
Separated
Widowed
Children: Yes / No
FILL IN:
I live with: ___________________
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My occupation Is: ________________
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Any recent travel (last 3 months)___________________ __
FAMILY HISTORY:
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Emphysema _____________
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Allergies _______________ __
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Asthma ____________
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Heart Disease __________
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Clotting Disorders ______
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Rheumatism _____
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Cancer _____________
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CHECK PROBLEMS YOU ARE HAVING OR HAVE HAD RECENTLY
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Shortness of Breath With Activity
Shortness of Breath at Rest
Productive Cough
Non-Productive Cough
Coughing up Blood
Chest Pain
Irregular Heartbeats
Acid Heartburn
Indigestion
Loss of Appetite
Weight Change
Abdominal Pain
Difficulty Swallowing
Sore Throat
 Tooth/Dental Problems
 Headaches
 Nasal Congestion/Difficulty Breathing
Through Nose
 Sneezing
 Itching
 Ear Ache
 Anxiety
 Depression
 Hand/Feet Swelling
 Joint Stiffness or Pain
 Rash
 Change in Color of Mucus
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. EVEN IF YOU HAVE NOT DONE SOME OF THESE THINGS RECENTLY TRY
TO WORK OUT HOW THEY WOULD HAVE AFFECTED YOU. USE THE FOLLOWING SCALE
TO SHOOSE THE MOST APPROPRIATE NUMBER FOR EACH SITUATION?
0 = No Chance of Dozing
1 = Slight Chance of Dozing
2 = Moderate Chance of Dozing
3 = High Chance of Dozing
SITUATION
Sitting and reading
Watching TV
Sitting inactive in a 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