CONCIERGE SLEEP MEDICINE
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Patient In-take Form
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Indicates required field
First Name
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Patient Ph
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Height
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E-mail
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Last Name
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Spouse Name
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Weight
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D O B
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Month/Date/Year
Spouse Ph
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B M I
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Age
*
PT Adress
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Neck Cir.
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Gender
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Select One
Male
Female
City
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Blood Pres.
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Race
*
Select
White
African
Asian
Latin
State
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Pulse
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Status
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Select One
Single
Maried
Separated
Divorced
Widowed
Zip Code
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Resp. Rate
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Current Complains
Was today a normal day?
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Select One
Yes
No
What happen?
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Are you in pain right now?
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Select One
Yes
No
Loud Snoring
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No
Yes
Some Times
Irritability
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No
Yes
Some Times
Restless Sleep
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No
Yes
Some Times
Daytime Sleepiness
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No
Yes
Some Times
Not Concentraiting
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No
Yes
Some Times
Insomnia
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No
Yes
Some Times
Morning Headaches
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No
Yes
Some Times
Memory Loss
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No
Yes
Some Times
Depression
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No
Yes
Some Times
Gasping For Air
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No
Yes
Some Times
Mouth Dryness
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No
Yes
Some Times
Shortness of Breath
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No
Yes
Some Times
Fatigue
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No
Yes
Some Times
Weight Gain
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No
Yrs
Some Times
Gastric Reflux
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No
Yes
Some Times
Comment
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Medical History
Have you had a Sleep Study Before?
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No
Yes
Where?
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When?
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Have you been treated for any condition in the last yeas?
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No
Yes
If yes, please describe
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Do you have?
Have you had?
Pacemaker
*
No
Yes
Defibrillator
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No
Yes
Stroke
*
No
Yes
Seizure
*
No
Yes
Habits
Alcohol
*
None
Light
Moderate
Heavy
Exercise
*
None
Light
Moderate
Heavy
Water
*
None
Light
Moderate
Heavy
Coffee
*
None
Light
Moderate
Heavy
Sleep
*
None
Light
Moderate
Heavy
Salty Foods
*
None
Light
Moderate
Heavy
Tabacco
*
None
Light
Moderate
Heavy
Appetite
*
None
Light
Moderate
Heavy
Sugary Food
*
None
Light
Moderate
Heavy
Drugs
*
None
Light
Moderate
Heavy
Soft Drink
*
None
Light
Moderate
Heavy
Artificial Sweetener
*
None
Light
Moderate
Heavy
Please mark any condition that you now have or you have had in the past:
Severe Headaches
*
No
yes
Hypertension
*
No
Yes
Stroke
*
No
Yes
Epilepsy
*
No
Yes
Fatigue
*
No
Yes
Dizziness
*
No
Yes
Anemia
*
No
Yes
Shortness of Breath
*
No
Yes
Asthma
*
No
Yes
Gout
*
No
Yes
Ears Ring
*
No
Yes
Chest Pain / Angina
*
No
Yes
Heart Palpitations
*
No
Yes
Heart Mumur
*
No
Yes
Arrhythmia
*
No
Yes
Congenital Heart Disease
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No
Yes
Rheumatic or Scarlet
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No
Yes
Gall Stomes
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No
Yes
Pancreatitis
*
No
Yes
Liver Disease
*
No
Yes
Arthritis
*
No
Yes
Alergies
*
No
Yes
Kidney Stones
*
No
Yes
Renal Disease
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No
Yes
Diabetes
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No
Yes
Endocrine Disease
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No
Yes
Urinary Problems
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No
Yes
Prostate Problems
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No
Yes
Sexual Dysfunction
*
No
Yes
Ovarian Cysts
*
No
Yes
Digestive Problems
*
No
Yes
HIV / AIDS
*
No
Yes
Cancer
*
No
Yes
Claudication
*
No
Yes
Ulcer
*
No
Yes
Venereal Disease
*
No
Yes
Mental Illness
*
No
Yes
Alcohol / Drug Problem
*
No
Yes
Low Back Pain
*
No
Yes
Shoulder Pain
*
No
Yes
Neck Pain
*
No
Yes
Knee Pain
*
No
Yes
Numbness Arms/Hands
*
No
Yes
Numbness Legs/Feet
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No
Yes
Family History
Father
*
Mother
*
Select One
*
Please Select One
95810
95811
Primary Dx Codes:
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Please Select One
327.23 OSA - Witnessd Breathing Pauses During Sleep
327.51 - Periodic Limb Movements During Sleep
333.94 - Restless Legs While Falling Asleep
347.00,01 - Narcolepsy - Daytime Sleep Attacks
780.51 - Insomnia With Apnea
780.52 - Insomnia Of Unknown Etiology
780.54 - Excessive Daytime Sleepiness/Hypersomnia
Other -
Supporting Dx (With a Primary Dx)
*
Please Select One
278.00 - Obesity
278.01 - Morbid Obesity
780.09 - Somnolence or Droesiness
780.79 - Fatigue or Malaise
786.09 - Loud or Disruptive Snoring
307.45 - Shift Work Disorder
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Understanding SDB 5
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