Sleep Patient Only

CIC Sleep Medicine Patient History Form
Name:
Date of Birth:
Allergies to medications: YES
NO
If yes, please identify Drug name and reaction:
Medications (please include over the counter meds and vitamins):
Medication name:
Dose
If you brought a list with you today, write see list
How many
tabs
How many times a
DAY
Medical History: Please circle those medical problems that you have been treated for:
Hypothyroidism
High Cholesterol
Atrial Fibrillation
Excessive Day Time Sleepiness
Anxiety
High Blood Pressure
Asthma
Insomnia
Back Pain
Iron Deficiency Anemia
Heart Disease (coronary artery disease)
Narcolepsy
Cancer: type
Osteoarthritis
year
.
Obesity
COPD
Sleep Apnea
Stroke-CVA
Parasomnia: example- sleep walking/talking
DVT (deep vein thrombosis)
Restless Legs Syndrome
Depression
Rheumatoid Arthritis
Diabetes
type 1
If diabetic is it: controlled or
type2
uncontrolled
Seasonal Allergies
Seizure Disorder
Fibromyalgia
Shift Work Disorder
GERD-heartburn
Please list any other conditions you have been
Head Injury
treated for that are not included above:
PE (pulmonary embolism)
.
Family History:
Does anyone in your family- (not including yourself) have or has had:
Please indicate which family member. MOTHER=M, FATHER=F, SISTER=S, BROTHER=B
Sleep Apnea
M
F
S
B
High Blood pressure
M
F
S
B
Narcolepsy
M
F
S
B
Diabetes Mellitus
M
F
S
B
Insomnia
M
F
S
B
Restless Leg Syndrome
M
F
S
B
Sleep Walking
M
F
S
B
Circadian Rhythm Disorder M
F
S
B
Sleep Talking
M
F
S
B
Any other diseases or disorders that are common in your family:
Stroke
M
F
S
B
Heart Disease
M
F
S
B
Unknown Family History
OR
Adopted
Social history: Please circle all that apply and fill in blanks as appropriate.
Tobacco:
NEVER
Cigarettes /Pipes /Cigars
Alcohol:
FORMER: how many packs/bowls per day
CURRENT: how many packs/bowls per day
Chew: how much per day
.
NEVER
OCCASIONAL:
how much/how often
. how many years did you smoke
. when did you quit
. how many years have you been smoking
.
.
Employment Status:
Hours you work-Shift:
.
LIGHT: less than 2 per day
Full-time Employment: Occupation
.
MODERATE: 2-3 drinks per day
Part-time Employment: Occupation
.
HEAVY: 4 more drinks per day
Unemployment
TYPE: Beer
Disabled—due to:
.
Living Situation:
Retired from:
.
Married, living with spouse
Caffeine-daily intake:
Single lives alone
Coffee - how many 8oz cups
Single living with significant other
Tea
how many 8oz glasses
Single living with family member
Soda
how many 12oz cans
Divorced
Energy Drinks
Widowed
What time do you stop drinking caffeine?
Wine
hard liquor
Past Surgeries:
.
Appendix Removal: yr
.
Coronary Artery Bypass Graft:
how many bypasses
Foot Surgery: type
.
Bariatric Surgery: type
yr
Cardiac Ablation: yr
.
.
How many stents if any
.yr
.
.yr
.
Hernia repair: umbical—inguinal—right—left. yr .
Hysterectomy: yr
.
Joint Replacement: Left Right. yr
Cardiac Catheterization:
.yr
Pacemaker—Defibrillator Placement: yr:
.
Carpal tunnel: Left - Right yr
. Cataract
Surgery: Left - Rightyr
.
Cesarean Delivery: yr
.
Gall Bladder Removal: yr
.
Please List any other Surgeries not included above and year:
.
which joint:
.
.
Cardioversion: (shocked your heart to regain normal rhythm)
how many
yr
.
Other Hospitlizations:
.
Please circle all that apply and fill in year of surgery.
Adenoids Removed: yr
Back Surgery: yr
NONE
Deviated Septum Surgery: yr
Sinus Surgery: yr
.
.
Thyroid Surgery: yr.
_.
Tonsils Removed: yr
.
Tubal ligation: yr
.
Vasectomy: yr
.

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