MRN:
Patient Name:
PATIENT INFORMATION- WELCOME LETTER/
DIRECTIONS TO UCLA SLEEP DISORDERS CLINIC
(Patient Label)
Welcome to the UCLA Sleep Disorders Clinic
The UCLA Sleep Disorders Clinic offer new patients and returning patients appointments at which
they meet with sleep specialists to discuss their problems, explain their medical histories, and
undergo physical examinations. A new appointment typically takes 60 minutes, whereas a return
appointment usually takes about 30 minutes.
An appointment at a UCLA Sleep Disorders Clinic is not an appointment for an overnight sleep
study, although some patients who are seen our Clinics do need such studies and can be
scheduled to have them on a subsequent night. The outpatient clinic appointments are critical to
the diagnosis and treatment of sleep disorders. A visit to our clinic allows for proper evaluation and
treatment of patients who have difficulties falling asleep or staying asleep at night, problems with
excessive daytime sleepiness, or other medical problems that may occur or exacerbate during
sleep. Often, this visit allows the clinicians to request a sleep study, when needed, that will make
use of equipment specifically tailored to the particular needs of the patient. At return visits,
clinicians can explain results of sleep studies, formulate treatment plans, and review progress.
Our department has earned an outstanding reputation in subspecialty care of sleep disorders due
to a high level of clinical expertise, academic achievement and innovative research. Our most
important mission is to provide each patient with the best sleep medicine health care available, by
combining our extensive experience with the latest advances in the treatment of sleep disorders.
Our faculty and staff work together as a team to bring each patient the highest quality of care in a
warm, friendly and professional environment.
We look forward to seeing you here.
UCLA Sleep Disorders Clinic Faulty and Staff
UCLA Neurology Clinic:
300 UCLA Medical Plaza, Suite B200
Box 956975
Los Angeles, CA 90095-6975
Website: http://www.neurology.ucla.edu (CLINICAL)
Phone: 310-794-1195
Fax:
310-794-7491
Medical Records: 310-825-6021
UCLA Form #520169 Rev. (01/12)
Page 1 of 3
MRN:
Patient Name:
PATIENT INFORMATION- WELCOME LETTER/
DIRECTIONS TO UCLA SLEEP DISORDERS CLINIC
(Patient Label)
To serve you best, we would like to tell you about our services.
Many people have managed health care coverage from health maintenance organizations (HMOs)
and preferred provider organizations (PPOs). Coverage and benefits vary widely. In most health
care plans, to see physicians trained in a certain area of medicine such as neurology, your visit and
any recommended tests from our doctors must be authorized by your primary care doctor's medical
group and your health plan in advance. You should have obtained a written authorization from your
health plan prior to making your appointment. Be sure to bring the authorization statement with
you to your appointment. If you are a Medicare member, you may have different coverage or
requirements.
We ask that you kindly familiarize yourself with your specific insurance benefits.
Often you will be asked to pay fees from $5 up to $50 (known as a co-payment) upon arrival. You
may find information on whether you are required to pay a copayment by reviewing your heath
plan booklet and your membership card.
If you do not have a written authorization for the visit or if your health membership card, or if you
do not have health insurance, the cost for the first visit ranges from $380 to $690. Payment by
cash, check or credit card is expected at the end of the visit.
Enclosed, please find the followings:
 Your appointment confirmation,
 Map to the UCLA Neurology Clinic
 Patient Questionnaire to be completed PRIOR to your appointment and to be
turned in to the receptionist upon arrival to our clinic.
Please plan to arrive at least 20 minutes prior to your appointment. You may be rescheduled
if you are more than 20 minutes late for your new visit
In order for us to serve you best, please remember to:
 Bring your medical insurance eligibility card
 Insurance claim forms (copayment and authorization documents)
 Pertinent medical records (Imaging, MRI, CT, EEG, EMG, sleep Studies and blood work).
 Names, complete addresses and telephone number of your referring physicians
 Completed patient questionnaire.
You MUST call us at least 72 hours in advance if you need to change your appointment.
If you fail to notify us of cancellation within 72 hours, you may be subjected to a $50 cancellation
fee. To rescheduel your appointment, please call (310) 794-1195.
DIRECTIONS TO THE UCLA NEUROLOGY- SLEEP CLINIC AT 300 UCLA MEDICAL PLAZA:
UCLA Form #520169 Rev. (01/12)
Page 2 of 3
MRN:
Patient Name:
PATIENT INFORMATION- WELCOME LETTER/
DIRECTIONS TO UCLA SLEEP DISORDERS CLINIC
(Patient Label)
 Your appointment is in 300 Medical Plaza about ½ block north of the intersection of
Westwood Boulevard and Le Conte Ave.
 From 405 North, exit Wilshire Blvd., Westwood.
 From 405 South, exit Wilshire Blvd., East.
 From Wilshire Blvd heading East, turn left (north) on Westwood Blvd.
 Proceed 4 blocks and cross Le Conte Ave.
 Turn left at the first signal light into the Medical Plaza driveway & proceed to Visitor Parking
(See Parking instructions below).
⇒ Proceed to 300 Medical Plaza (Three story Building with Clock). The Neurology
Clinic is located in the “B 1” (Basement Level) Suite 200.
PARKING
Follow the one-way circular driveway. Take the ramp into underground parking on your left side.
Proceed to the parking area for 200 & 300 UCLA Medical Plaza. The parking fee is $11 per car
entry. Handicapped parking is available at the underground entrance of 300 Medical Plaza.
There is a $3.00 parking charge for visitors displaying valid handicapped plates or placards.
PATIENT DROP-OFF AREAS LOCATIONS OF CLINIC
A drop-off area is located in front of the 300 Medical Plaza (Building with clock) on the circular
driveway at the street level. Take the elevator to level B1. In the underground parking structure,
you will enter on level B1.
Follow the sign to Neurological Services, Suite B200.
UCLA Form #520169 Rev. (01/12)
Page 3 of 3
MRN:
Patient Name:
GENERAL HEALTH QUESTIONNAIRE
UCLA SLEEP DISORDERS CLINIC/ CENTER
PATIENT INFORMATION
Last, First, Middle Name
Age
(Patient Label)
Today’s Date
Birth Date
Sex:
Native Language:
Male / Female
Referring Physician’s Full Name
Telephone #:
Physician’s Address
Are you:
Right-handed
Left-handed
Ambidextrous
Why do you need to see a Neurology specialist?
Past Medical History
Date Diagnosed
Hospitalizations, Operations and dates
Injuries and dates. Include any episodes of loss of consciousness.
Blood Transfusions and dates
Drug Allergies and reactions:
UCLA Form #520171 Rev. (01/12)
Page 1 of 4
MRN:
Patient Name:
GENERAL HEALTH QUESTIONNAIRE
UCLA SLEEP DISORDERS CLINIC/ CENTER
Medications (current and/or recent)
Name
Dosage
(Patient Label)
How often?
(*Attached typed sheet/write on back if necessary)
Dietary Supplements/Vitamins:
Name
Dose & Frequency
Social History
Any use of tobacco (type and for how long)?
Any use of caffeinated beverages?
Any use of alcohol (type and for how long)?
Any use of recreational drugs (type and for how long)?
Any exposure to toxins/poisonous substances at work or with hobbies?
What type of work do you do?
Education:
Grade School
Marital Status:
Single
High School
Married
College
Divorced
Post-Graduate
Voc. Training
Separated
Widowed
Birthplace:
UCLA Form #520171 Rev. (01/12)
Page 2 of 4
MRN:
Patient Name:
GENERAL HEALTH QUESTIONNAIRE
UCLA SLEEP DISORDERS CLINIC/ CENTER
(Patient Label)
FAMILY HISTORY
Mother: Living or deceased?
Health Problems:
Age:
Father: Living or deceased?
Health Problems:
Age:
Brothers/Sisters: List from the oldest to youngest.
1. Brother or sister?
Health problems:
Living or deceased?
Age:
2. Brother or sister?
Health problems:
Living or deceased?
Age:
3. Brother or sister?
Health problems:
Living or deceased?
Age:
4. Brother or sister?
Health problems:
Living or deceased?
Age:
Children: List from oldest to youngest.
1. Daughter or son?
Health problems:
Living or deceased?
Age:
2. Daughter or son?
Health problems:
Living or deceased?
Age:
3. Daughter or son?
Health problems:
Living or deceased?
Age:
Have any of your family or relative had the following health conditions? If yes, whom?
Heart disease
High blood pressure
High cholesterol
Loss of memory
Epilepsy/seizures
Depression
Mental disease
Muscle weakness
Other:
UCLA Form #520171 Rev. (01/12)
Stroke
Fainting
Diabetes
Cancer
Multiple sclerosis
Polio
Limping
Thyroid disease
Page 3 of 4
MRN:
Patient Name:
GENERAL HEALTH QUESTIONNAIRE
UCLA SLEEP DISORDERS CLINIC/ CENTER
(Patient Label)
REVIEW SYSTEMS
Please place a checkmark if you currently have any of the following symptoms.
1. "constitutional”
fever
weight loss
fatigue
2. “eyes problem”
blurred vision
eye pain
double vision
eye redness
loss of vision
eye dryness
3. “ear/nose/throat”
trouble hearing
loss of balance
hoarseness
ringing in ear(s)
ear pain
trouble swallowing
dizziness (vertigo)
ear discharge
slurred speech
4. “cardiovascular”
chest pain
limb swelling
irregular heart beat
limb pain on walking
fast heart beat
fainting
5. “respiratory”
trouble breathing
chronic cough
coughing blood
6. “gastrointestinal”
indigestion
nausea
diarrhea
heart burn
vomiting
constipation
abdominal pain
regurgitation
bloody stools
7. “genitourinary”
incontinence
pain on urination
blood in urine
8. “musculoskeletal”
muscle pain
loss of muscle bulk
joint pain
muscle cramp
neck pain
joint stiffness
muscle twitches
back pain
joint swelling
9. “skin & breast”
numbness
tingling
discoloration
10. “neurologic”
headache
weakness
blackouts
face pain
tremors
trouble with memory
face numbness
clumsiness
trouble concentrating
11. “psychiatric”
hallucinations
suicidal thoughts
feeling depressed
inappropriate crying
trouble sleeping
inappropriate laughing
12. “hematologic/lymphatic”
abnormal bleeding
nose bleeds
lumps or swellings
13. “allergic/immunologic”
skin rash
joint pain
dry eyes & or dry mouth
14. “endocrine”
excessive thirst
heat or cold intolerance
excessive urination
Patient or Representative Signature: __________________________ Date: _______ Time: _______
If signed by someone other than the patient, please specify relationship to the patient: ___________
For office use: This questionnaire may be completed by the patient, relative or ancillary staff provided that it is
signed and dated by the treating physician. (Reference may later be made to this information by a signed and
dated statement by the treating physician, designating location of the information, date obtained and any
subsequent charges.)
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Physician’s Signature: _________________________ Pager: _______Date: _______Time: _______
UCLA Form #520171 Rev. (01/12)
Page 4 of 4
MRN:
Patient Name:
SLEEP QUESTIONNAIRE
UCLA SLEEP DISORDERS CLINIC/ CENTER
MARITAL STATUS:
Single
Married
Divorced
Widow(er)
(Patient Label)
Separated
Living together
OCCUPATION: ___________________________________
SLEEP QUESTIONNAIRE
My main sleep complaint is:
Trouble sleeping at night
Being sleepy all day
Unwanted behaviors during sleep
Explain: ______________________________________________________________________
Other (explain): ______________________________________________________________
USUAL SLEEP HABITS:
Bedtime: ______
am
pm Number of awakenings: ______
Wake time: ______
am
pm Number of naps/week:
______
Duration of sleep problem: ______
DIRECTIONS: Check any statement which currently applies to you:
unrefreshing naps
dreams or hallucinations while awake
dream a lot
sudden feeling of weakness in knees or legs
was a hyperactive child or teenager
difficulty waking up in the morning
use sleeping pills
function best in the evening
bed partner disturbs sleep
don't feel tired at bedtime
heart pain during the night
shift-worker or night work
awaken with back pain
restlessness, tingling, or crawling in legs
restless sleeper
sleep talking as adult
trouble falling asleep
banging, twisting or shaking head in sleep
awaken long before it is necessary
sudden awakening w/intense anxiety or dread
sleep better in unfamiliar setting
grind teeth in sleep
light sleeper
sleepwalking as an adult
trouble returning to sleep
bedwetting in adulthood
stop breathing during sleep
awaken with heartburn
gained more than 10 lbs in the last year
cough up sputum or mucus at night
unable to sleep in a flat position
kicking or twitching during sleep
jaws ache in morning
legs jerk during sleep
bitter or sour mouth taste in morning
experience inability to keep legs still
very loud snorer
nocturnal seizures
awaken with headaches
bitten tongue during sleep
have high blood pressure
WOMEN
awaken with choking sensation
sleep problem varies with menstrual cycle
driving accidents or near-accidents due to
sleep problem started/ got worse at menopause
sleepiness
currently taking hormonal pills
paralysis or inability to move on awakening
MEN
driven miles past destination w/ little awareness
awaken with painful penile erections
falling asleep at inappropriate times
problems obtaining/ maintaining erections
refreshing naps
UCLA Form #520172 Rev. (01/12)
Page 1 of 4
MRN:
Patient Name:
SLEEP QUESTIONNAIRE
UCLA SLEEP DISORDERS CLINIC/ CENTER
(Patient Label)
EPWORTH SLEEPINESS SCALE
The Epworth Sleepiness Scale (ESS) is a standardized a self-administered 8-item questionnaire
commonly used to assess sleepiness.
Patients are given the following instructions:
The questionnaire asks you to rate the chances that you would doze off or fall asleep during
different routine situations. Answers to the questions are rated from 0 to 3, with 0 meaning you
would never doze or fall asleep in a given situation, and 3 meaning that there is a very high
likelihood that you would doze or fall asleep in that situation.
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
Chance of Dozing
Situation
Never
(0)
Slight
(1)
Mod
(2)
High
(3)
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 without a break - Lying down to rest in the afternoon when
Sitting and talking to someone - - - - - - - - - - - - - - - - Sitting quietly after a lunch without alcohol - - - - - - - In a car, while stopped for a few minutes in traffic - - - - - - - - - -
UCLA Form #520172 Rev. (01/12)
Page 2 of 4
MRN:
Patient Name:
SLEEP QUESTIONNAIRE
UCLA SLEEP DISORDERS CLINIC/ CENTER
(Patient Label)
DAILY SLEEP LOG
To help us understand your sleep problems, we need a report of the times when you sleep, nap and
wake-up during sleep. In addition, we need to know the times when you drink coffee, tea and alcoholic
beverages. If medication is taken, record the time medication is needed. It is important that you keep
this record for 7 days. Each column begins with a new day. The first column is an example for you to
study. If you have any questions, call the UCLA Sleep Disorders Center. "A" indicates AM (morning),
"P" indicates PM (afternoon or evening).
DATE: Please be sure
Example:
to write the date
10/7
Bedtime
11:00 PM
Estimated time it took
to fall asleep
45 min.
Time of awakenings
during sleep and length
of time you were awake
2 A – 1 hr
3 A – 1 hr
Time of final awakening
in the morning
5:30 AM
Total night’s sleep
3 hrs
Naps, times you napped,
& length of naps
2P
45 min.
Medications taken, times
and amounts
Dalmane
30 mg
10:30 PM
Coffee and tea, number
of cups and time drank
7:00 A - 1
Alcoholic drinks, number
and time drank
8:00 P – 1
9:00 P – 1
10:00 P – 1
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Evening activities for each day:
1. _____________________________________________________________________________
2. _____________________________________________________________________________
3. _____________________________________________________________________________
4. _____________________________________________________________________________
5. _____________________________________________________________________________
6. _____________________________________________________________________________
7. _____________________________________________________________________________
UCLA Form #520172 Rev. (01/12)
Page 3 of 4
MRN:
Patient Name:
SLEEP QUESTIONNAIRE
UCLA SLEEP DISORDERS CLINIC/ CENTER
(Patient Label)
PATIENT HEALTH QUESTIONNAIRE (PHQ-9)
Over the last 2 weeks, how often have you been bothered by any of the following problems?
(Please circle to indicate your answer)
Not at all
Several days
1. Little interest or pleasure in doing things
0
1
2
3
2. Feeling down, depressed, or hopeless
0
1
2
3
3. Trouble falling or staying asleep, or sleeping too much
0
1
2
3
4. Feeling tired or having little energy
0
1
2
3
5. Poor appetite or overeating
0
1
2
3
6. Feeling bad about yourself — or that you are a failure or
have let yourself or your family down
0
1
2
3
7. Trouble concentrating on things, such as reading the
newspaper or watching television
0
1
2
3
8. Moving or speaking so slowly that other people could have
noticed? Or the opposite — being so fidgety or restless
that you have been moving around a lot more than usual
0
1
2
3
9. Thoughts that you’d be better off dead or hurting yourself?
0
1
2
3
______
______
Score
More than
Nearly every
half the days day
______
______
How difficult have these problems made it for you to do your work, take care of things at home, or get
along with other people?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Total PHQ-9 Score: _________
Patient or Representative Signature: __________________________ Date: _______ Time: _______
If signed by someone other than the patient, please specify relationship to the patient: ___________
UCLA Form #520172 Rev. (01/12)
Page 4 of 4
MRN:
Patient Name
SPOUSE or ROOMATE QUESTIONNAIRE
SLEEP DISORDERS CLINIC/ CENTER
(Patient Label)
To be completed by Bed – partner, Family member or Roomate
Check any of the following behaviors that you have observed the patient do while he/she is asleep:
Loud snoring
Light snoring
Twitching of legs or feet during sleep
Pause in breathing
Grinding teeth
Sleep talking
Sleep walking
Pause in breathing
Bed wetting
Sitting up in bed but not awake
Head rocking or banging
Kicking with legs during sleep
Getting out of bed but no awake
Biting tongue
Becoming very rigid and / or shaking
How long have you been aware of the sleep behavior(s) checked above?
Describe the behavior(s) checked above in more detail. Include a description of the activity, the time
during the night when it occurs, it’s frequency during the night, and whether it occurs every night.
If you heard loud snoring, do you remember hearing short pauses in the snoring or occasional loud
“snorts”?
Yes
No
Describe:
Spouse or Roomate Signature: _____________________________ Date: ________Time: ________
UCLA Form 520166 Revised (01/12)
Page 1 of 1