As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.
Patient Information
If you are completing this form for another person, what is your relationship to that person?
Sleep Information
Have you or any family member have history of the following?
Have you experienced any of the following?
Epsworth Sleepiness Scale
How likely are you to doze off or fall asleep in the following circumstances, in contrast to feeling just tired? This refers to your usual way of life in recent times. Using the scale below, select the most appropriate number for each situation.
Scale:
- 0- Would Never Fall Asleep
- 1- Slight Chance of Dozing
- 2- Moderate Chance of Dozing
- 3- High Chance of Dozing
Medical Information
Women Only Are you:
Allergies Please mark "Yes" if you are allergic to (or have had a reaction to) the following.
Please mark "Yes" if you have (or have had) any of the following diseases or problems.
Pharmacy Information
Signature
NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.
All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
