Habits Please give details of your personal habits
Tobacco
Alcohol
Caffeine
Medication
Name of Drug
Doses per day
Dosage
Reason
Allergies Please give details, describe your reaction
Previous Sleep Study? (date)
current settings
Surgeries / Operations Please give details, date
Other Medical Problems Please give details, date
Family History Does anyone in your family have a sleep disorder,
List significant family illnesses, give details
Epworth Sleepiness Scale Referring to your usual way of life, how likely are you to doze off or fall asleep during the following situations?
Or refer to a specific time when the following does apply! ( 0=No Chance, 1=Slight Chance, 2= Moderate Chance, 3= High Chance)
Sitting and reading
Watching TV
Sitting, 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 circumstances allow it
Sitting down and talking to someone
Sitting quietly after lunch without alcohol
In a car, while stopped in traffic for a few minutes
Sleep Questionnaire
Sleep - Wake Schedule:
Bedtime?
Awakening time?
Alarm clock?
Do you wake up during the night? (yes,no)
How many times?
For how long?
How long does it take you to fall asleep?
Disturbed Sleep:
Yes
No
Do you snore?
Have you lost your bed partner because of this?
Have breathing pauses been observed?
Have you been told your limbs kick or twitch?
Talk in you sleep?
Walk in your sleep?
Act out vivid or violent dreams?
Insomnia:
Yes
No
Do you have trouble falling asleep?
How long does it take you?
How many nights per week?
If you wake up during the night, do you
Have trouble going back to sleep?
How long does it take you?
How many nights per week?
Do you have an aching, uncomfortable or squirmy
sensation in your legs, which keep you from sleeping?
Are you a light sleeper, easily awakened?
Past Sleep History:
Yes
No
Did your current sleep problem begin in childhood?
Were you considered hyperactive or hyper kinetic as a child or teenager (Attention Deficit Disorder)?
Daytime Sleepiness:
Yes
No
Are you sleepy or tired all day?
Have you had accidents or near accidents because of sleepiness?
Have you "come to" or suddenly become alert and found yourself doing things
without being aware of having started them remembering how you got there?
Have you experienced sudden weakness in the legs or body in general,
while awake, perhaps after being startled or in an emotional situation?
Have you had hallucinations or dream like images
While awake?
While falling asleep?
Do you take naps during the day?
How many days per week?
How long are the naps?
Are they refreshing?
Do you dream during your naps?
Did you fall asleep, or fight the urge to fall asleep in school as a child or adolescent?
Spouse, Roommate, or Bed Partner Questionnaire:
(to be filled out about you by your spouse, roommate,
or bed partner-not about you spouse, roommate, or bed partner)
Never
Occasionally
Frequently
Does he / she snore?
Does he / she stop breathing?
Does his / her legs or body twitch or kick?
Does he / she grind his / her teeth?
Does he / she walk in his / her sleep?
Does he / she sit up in bed while not awake?
Does he / she become rigid or shake during sleep?
Insurance Information
PRIMARY INSURANCE:
Company Name:
Mailing Address:
Zip Code:
City/State:
Relationship to Patient:
Name of Subscriber:
Subscriber's DOB:
Policy Number:
Group Number:
ID Number:
Effective Date:
SECONDARY INSURANCE COMPANY:
Company Name:
Mailing Address:
Zip Code:
City/State:
Relationship to Patient:
Name of Subscriber:
Subscriber's DOB:
Policy Number:
Group Number:
ID Number:
Effective Date:
Payment Policy:Payment is due at the time services are rendered unless other arrangements have been made. Insurance is considered a method of reimbursing the patient for fees paid to the doctor, and is not a substitute for payment. It is your responsibility to pay any deductible, co-insurance, or any balance not paid by your insurance. Our Policy allows a maximum of 90 days for insurance companies to pay claims. If this does not occur, you will be expected to pay the balance to NYX
Patient Authorization: I hereby authorize the release of any medical information necessary to process my insurance claim. I hereby authorize payment of medical benefits to the named provider for services rendered. I also authorize Palmetto GBA to release information regarding Medicare claims submitted by the named provider.
This office requires a 48-hour advance notice of cancellation when a sleep study has
been scheduled. If not given, NYX reserves the right to charge a $175 non-refundable
fee to the person responsible for the patient listed above and/or decide if the patient will
be re-scheduled for a later date.
SIGNED: _________________________________________________ DATE: _________________ (Patient or Guardian if Minor)
Please print out this form and mail or fax it to:
NYX Sleep Disorders Center
25050 Peachland Ave Suite 125
Santa Clarita, CA 91321
Fax: 661.799.0968