Patients

What to Expect

A comprehensive evaluation will be conducted at your initial consultation appointment with SMA.

Initial Consult

● Sleep History Evaluation

● Medical History

● Social/Psychological History

● Screening Questionnaires

Testing Options

● Overnight Sleep Test (PSG)

● Home Sleep Test (HST)

● Multiple Sleep Latency Test (MSLT)

● Maintenance Wakefulness Test (MWT)

New Patient Paperwork

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New Patient Paperwork SMA
Martha Hagaman M.D.

New Patient Paperwork SMA Martha Hagaman M.D.

Date

MM slash DD slash YYYY

Patient Name

DOB

MM slash DD slash YYYY

Phone Number

Patient Height

Weight: ___ lbs

Referring Physician

Neck Size

Main Sleep Problems

1. My main sleep complaint is: __ Trouble Sleeping at night ____ Sleepy during the day ______ Unusual behavior during sleep (gasping, snoring, kicking, etc.)

2. How many nights per week do you have a sleep problem? ________ nights/wk.

3. Have you been diagnosed with a sleep problem in the past? _____ yes ____no If yes, briefly explain:

4. Does your sleep problem disturb your bed partner?

Yes

Sleep Schedule

5. On normal weekdays Bedtime:_____p.m. Wake up: ____

6. On days off Bedtime: Wake up: ______ a.m.

7. Do you maintain a fairly regular sleep/wake schedule?

Yes

8. Do you take naps frequently?

Yes

If so, do they make you feel refreshed

Yes

9. Do you read or watch TV in bed?

Yes

Falling Asleep

10. Do you often have trouble falling asleep?

Yes

11. Do you wake up too early without being able to fall back asleep?

Yes

12. On average, how long does it take to fall asleep? ______ hrs _____ min.

13. On average, how many times do you awaken during the night? _____times

Movements During Sleep

14. Do you awaken yourself by kicking or jerking your legs?

Yes

15. Does your bed partner complain of your leg movements?

Yes

16. Do you ever have a restless, aching or burning sensation in your legs prior to going to sleep?

Yes

17. Do you exercise regularly?

Yes

18. Do you have any other movements in your sleep (walking, tooth grinding, etc.)

Yes

If yes, briefly explain: tooth grinding, groaning, leg slamming

19. Do you currently have nightmares or night terrors?

Yes

Snoring

20. Have you ever been told you snore?

Yes

21. Have you ever been told you stop breathing during sleep?

Yes

22. Do you have frequent headaches in the morning?

Yes

23. Is your throat dry or sore in the morning?

Yes

24. Have you ever had trauma or surgery to your upper airway?

Yes

25. If yes, briefly explain:

Other Symptoms:

26. Do you ever experience hallucinations when falling asleep or waking up?

Yes

27. Do you ever experience paralysis or inability to move while awake in bed?

Yes

28. Do you ever experience a sudden loss of muscle tone associated with a change in emotion, such as laughter, anger, etc?

Yes

Medical History

29. List any current medical problems such as high blood pressure, heart or lung disease, stroke, diabetes etc.: ___Prediabetes, chronic migraine, PTSD, anxiety, depression, IBS, bone marrow donor, diarrhea, allergic rhinitis, central sensitization to pain

30. Are you allergic to any medications?

Yes

If so, what? _____ Sulfa antibiotics (bactrim)

31. Have you smoked cigarettes?

Yes

How many years?

What year did you quit?

Do you currently smoke?

Yes

How many packs per day?

32. On average, how many caffeinated drinks do you consume per day? _________/day

33. On average, how many alcoholic drinks do you consume per day? ___________/day Family History

34. Does anyone in your family have a sleep problem?

Yes

If yes, briefly explain:

Phone

This field is for validation purposes and should be left unchanged.

We look forward to meeting you at your consultation appointment, and we thank you for choosing SMA.

Physician Referral

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Physician Referral for Martha Hagaman M.D.

Patient Name:

DOB:

MM slash DD slash YYYY

Address

Street Address City State / Province / Region ZIP / Postal Code

Daytime Phone:

Alternate Phone:

Primary Insurance:

ID#:

Group:

Suspected Disorder (Check all that apply)

Obstructive Sleep Apnea

Narcolepsy

Nocturnal Seizures

Insomnia

Periodic Limb Movements

Other:

This patient is being referred for: (Please check all that apply)

Sleep Study/Titration/PAP-NAP if needed

Multiple Sleep Latency Test (Following overnight sleep study)

CPAP Titration

Maintenance of Wakefulness Test

Pap-Nap

Other:

Sleep Consultation with Sleep Specialist Physician for Evaluation, Diagnostic Testing and Treatment

Other:

Relevant Medical History (Please forward most recent history and physical) - Primary Symptoms:

Witnessed Apnea

Frequent Snoring

Mood disorder

Hypertension

Obese/Large neck

Difficulty falling asleep

Difficulty staying asleep

History of stroke

Excessive daytime sleepiness

Impaired cognition

Insomnia

Ischemic heart disease

Frequent leg movements during sleep

Other:

Special Needs:

Nocturnal O2

Wheelchair

Other:

Comments:

***IF patient requires CPAP, please list your medical equipment company (DME) of preference along with any specific equipment requests:

Referring Physician:

NPI#:

Address

Phone

Fax:

(Reports will be faxed here)

Signature:

Date:

MM slash DD slash YYYY

** Most insurances now require a copy of the patient progress notes. Please forward a copy of the notes with this referral**

Comments

This field is for validation purposes and should be left unchanged.