ATLANTIC SLEEP & PULMONARY ASSOCIATES – Initial Intake Form - 1
NAME: _____________________________________________ DATE:_______________________
THANK YOU for trusting us with your health care!
In order to provide you with the best quality of care, please take a few moments and fill out the information below.
What is your reason for today’s visit? (circle one)
Initial evaluation
Scheduled follow-up Unscheduled follow-up
Emergency visit
MEDICAL HISTORY - CURRENT OR PAST DIAGNOSES: (circle all that currently apply)
ALLERGY/SINUS
Nasal Polyps
Nosebleeds
Rhinitis/Nasal Congestion
Seasonal Allergies
Sinusitis
Other: _________________
CARDIOLOGY
Atrial Fibrillation
Angina/Chest Pain
Arrhythmias
Congestive Heart Failure
Heart Attack
Hypertension
Mitral Valve Prolapse
Other: _________________
ENDOCRINOLOGY
Cholesterol/Lipid Issues
Diabetes
Thyroid Problems
Other: _________________
PULMONARY
Bronchitis
Lung Abscess
Pneumonia
Sinusitis
Tuberculosis
EYES
Cataracts
Glaucoma
Retina Issues
Other: _________________
GASTROINTESTINAL
Acid Reflux/Heartburn
Bleeding
Colitis/Irritable Bowel
Diverticulitis
Gall Bladder Issues
Hemorrhoids
Hiatal Hernia
Ulcer
Other: _________________
HEMATOLOGY/ONC
Anemia
Cancer – Any Type
Clotting Abnormalities
Phlebitis
Other: _________________
Asthma
COPD
Emphysema
Bronchiectasis
Positive PPD
NEUROLOGIC/PSYCH
Anxiety
Depression
Headaches
Psychosis
Multiple Sclerosis
Neuropathy
Parkinson’s Disease
Schizophrenia
Seizures
Stroke
TIA
Tremor
Other: _________________
INFECTIONS
Hepatitis
HIV +
Lyme
Other: _________________
UROLOGY
Bladder Issues
Kidney Dysfunction
Kidney Stones
Enlarged Prostate
Urinary Tract Infections
Other: _________________
GYNECOLOGY
Abnormal Bleeding
Fibroids
Other: _________________
RHEUMATOLOGY
Arthritis
Gout
Lupus
Scleroderma
Osteoporosis/Osteopenia
Rheumatoid Arthritis
Other: _________________
SKIN
Eczema
Hives
Psoriasis
Rash
Other: _________________
OTHER
Fibromyalgia
Chronic Fatigue Syndrome
Scoliosis
Other: _________________
Collapsed Lung
Pulmonary Embolism
Sarcoidosis
Pleural Effusion Lung Cancer
Blood Clot in Lung
Pneumothorax
Lung Mass/Nodule
Pulmonary Hypertension
Chronic Cough
Pulmonary Fibrosis
Coughing Up Blood
Other: ___________________________________________________________________
SLEEP
Snoring
Insomnia
Periodic Limb Movements Teeth Grinding
Sleep Eating
Sleep Apnea
Shift Work Disorder
Restless Leg Syndrome
Sleepwalking
Night Terrors
Central Apnea
Hypersomnia
Narcolepsy
REM Behavior Disorder
Other: ___________________________________________________________________________________________________
SURGICAL HISTORY: (please list, with approximate dates if you know) ________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
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ATLANTIC SLEEP & PULMONARY ASSOCIATES – Initial Intake Form - 2
NAME: _____________________________________________ DATE:_______________________
CURRENT SLEEP SYMPTOMS: (circle all/any of the following that currently apply)
Snoring – Irregular breathing - Non-restorative sleep – Fragmented sleep – Problems initiating sleep
Problems maintaining sleep – Periods of inappropriate sleep – Intrusive leg twitching – Restless leg symptoms
Sleepwalking – Teeth grinding – Inappropriate behavior at night – Nightmares – Night terrors - Daytime sleepiness
OTHER: ____________________________________________________________________________________
CURRENT RESPIRATORY AND GENERAL SYMPTOMS: (circle any/all of the following that currently apply)
Change in appetite - Chills – Fatigue – Fever –Headache – Lightheadedness - Sweats - Weight loss – Blurred vision
Itching/redness of the eyes - Pain of the eyes - Nasal drip – Hoarseness - Nasal congestion – Nasal discharge
Decreased hearing - Decreased sense of smell - Problems swallowing – Nosebleed - Sinus pain - Sore throat
Chest tightness – Chest congestion - Chest pain - Cough – Coughing up blood - Shortness of breath at rest
Shortness of breath with exertion – Sputum production – Wheezing – Difficulty lying flat – Palpitations
Abdominal pain – Constipation - Diarrhea – Heartburn – Nausea – Vomiting –Blood in urine - Pain or difficulty
while urinating - Frequent urination - Erectile dysfunction - Muscle pain – Joint pain - Swollen joints – Leg/ankle
swelling - Rash – Fainting – Dizziness - Weakness – Headache – Low back pain - Tremor
OTHER:____________________________________________________________________________________
HEALTH HABITS: (circle answer or fill in the blank)
Have you ever smoked cigarettes regularly: YES / NO If yes, total years smoking: ____ Do you smoke now: YES / NO
If no, how many years ago did you quit? _____ About how many packs/day on average did you smoke: _____
Do you drink alcohol? YES / NO
Do you exercise?
Regularly
If yes, how many drinks do you average/week: ________
Occasionally
No
Exercise Level: Vigorous
Moderate
Light
What is your current/prior occupation(s): ___________________________________________________________________
____________________________________________________________________________________________________
EPWORTH SLEEPINESS SCALE:
How likely are you to doze off or fall asleep in the following situations, in contrast to just 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 work out
how they would affect you. Use the following scale to choose the most appropriate number for each situation
(select only one answer for each situation).
0 = would never doze
2 = moderate chance of dozing
1 = slight chance of dozing
3 = high chance of dozing
Situation
Sitting and reading
Watching TV
Sitting inactive in a public place (e.g. theater)
As a passenger in a car for 1 hour without a break
Lying down 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
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0
1
2
3
ATLANTIC SLEEP & PULMONARY ASSOCIATES – Initial Intake Form - 3
NAME: _____________________________________________ DATE:_______________________
HEALTH MAINTENANCE: (circle answer and provide date if available)
Last Cardiac Stress Test: YES / NO ______________ Last Bone Density Test: YES / NO ________________
Last Mammogram: NA / YES / NO ______________ Last GYN Exam: NA / YES / NO __________________
Last Flu Shot: YES / NO ______________
Last Pneumonia Vaccine:YES / NO ________________
Last Chest X-Ray (date/loc): ___________________
Last CT Chest (date/loc):___________________________
FAMILY HISTORY:
Relative
Mother
Father
Sibling
Sibling
Alive
Deceased
Present state of health, major illnesses, and/or cause of death
Other significant family medical history:__________________________________________________________________
Please fill out the following sections ONLY if you are currently being treated for sleep apnea:
SLEEP TREATMENT QUESTIONS:
Are you generally satisfied with your sleep treatment at this time?
Do you feel that the current treatment is effectively managing your sleep condition?
YES
YES
NO
NO
SLEEP EQUIPMENT QUESTIONS:
If you are on CPAP or BiPAP, please answer the following questions:
Are you having problems with your mask?
Are you having issues with excessive dryness?
Are nasal/sinus issues affecting your ability to use CPAP/BiPAP?
Are you snoring despite using the PAP equipment?
Are you having any problems with your Home Care company?
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
SATISFACTION SCORE:
Please rate your overall satisfaction with your PAP therapy:
(Terrible) 1
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2
3
4
5
6
7
8
9
10 (Great)