Download NEUROLOGY PHYSICIANS LLC

NEUROLOGY PHYSICIANS LLC
Merrill Ansher, M.D. , Yingjun David Li, M.D., Johannes Reim, M.D.
Board Certified in Neurology
SLEEP-WAKE DISORDERS CENTER OF COLUMBIA
C. Rider Brandau, RPSGT
Columbia Medical Center
11055 Little Patuxent Parkway, Suite 209
Columbia, MD 21044
Phone: 410/884-0191
Fax: 410/997-2607
RIDER’S CELL PHONE FOR AFTER HOURS CONTACT CONCERNING YOUR SLEEP STUDY APPT:
443-996-1659
_____________________________________________________________________
You are scheduled for the following appointment with Neurology Physicians/
Sleep-Wake Disorders Center of Columbia:
_____
Polysomnogram
_____
CPAP Study
_____
MSLT
Date of appointment: ________________________________________
Please arrive in the office at 8:00 p.m. on the night of your appointment. IF THE FRONT
DOOR TO BUILDING IS LOCKED, CALL RIDER ON HIS CELL LISTED ABOVE. It
takes approximately 45 minutes per Patient to prepare for the test. Lights Out will be at 10:00
p.m.. Unless you are scheduled for a daytime study (MSLT), you will be ready to leave the office
by 6:00 a.m. the next morning. Please take some time to complete the enclosed sleep
questionnaire and bring it with you to your appointment. If your insurance requires referrals,
please check to make sure it is made out for Neurology Physicians or to Dr. Ansher, Reim or Li.
Bring your referral to your appointment as well.
The Sleep Lab bedrooms are equipped with a bed, small Bedside Table and a television. A
refrigerator and microwave are available should you need them. If you are staying for an MSLT,
you will need breakfast and lunch for the following day as you may be in our offices until the
afternoon. Bring comfortable night clothes.
It is required to give our office 48 hours notice (weekdays, Monday-Friday, 9:00a.m.-4:30 p.m..)
if you find it necessary to cancel your appointment to avoid a cancellation fee of $250.00
If you need to contact our office concerning appointment questions, please call 410/884-0191.
If you have technical questions and wish to speak to the technologist, please call 410/992-5161.
SLEEP-WAKE DISORDERS CENTER OF COLUMBIA
C. RIDER BRANDAU, RPSGT
MANAGER/TECHNOLOGIST
11055 Little Patuxent Parkway, Suite 209
Columbia, MD 21044
410/992-5161
_______________________________________________________________________
PRELIMINARY SLEEP QUESTIONNAIRE
Please answer all of the following questions and bring this questionnaire with you to your
appointment.
Name__________________________________
Referring Physician___________________________
Date___________________________________
Physician’s Specialty__________________________
Birthdate_______________________________
Sex____Height____Weight____
BACKGROUND INFORMATION
Describe your problem and why you have been referred to the Sleep Center
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
How long have you had your sleep-related problems?___________________years/months
Using the following rating scale, to what extent do you currently experience the following symptoms?
(If not applicable, circle N/A)
M
I
L
D
M O D E R A T E
S E V E R E
Daytime Sleepiness
1
2
3
4
5
6
7
8
9
10
N/A
Snoring
1
2
3
4
5
6
7
8
9
10
N/A
Difficulty Falling Asleep
1
2
3
4
5
6
7
8
9
10
N/A
Difficulty Staying Asleep
1
2
3
4
5
6
7
8
9
10
N/A
Walking, Talking or other
Unusual Behaviors During
Sleep
1
2
3
4
5
6
7
8
9
10
N/A
Daytime Deficits in
Concentration, Memory,
Motivation or Mood
1
2
3
4
5
6
7
8
9
10
N/A
Obtain too little sleep
1
2
3
4
5
6
7
8
9
10
N/A
Obtain too much sleep
1
2
3
4
5
6
7
8
9
10
N/A
Do any of your sleep or sleepiness problems seem to show a cycle, or recur at regular intervals? YES NO
Have your sleep or sleepiness problems ever been worse at any time in the past? YES
NO
Do any of the following factors typically affect (either positively or negatively) your level of daytime sleepiness or
the quality of your nighttime sleep? (Circle the ones that apply):
Tea
Coffee
Sodas
Alcohol
daytime nap
daytime rest
physical exercise
physical fatigue
anxiety/worry
mental stress
adolescence
Cold
Heat
Noise
Seasons
Types of weather
after pregnancy
menopause
menstrual cycle
pregnancy
holidays
shift work
unfamiliar bed
weekends
FALLING ASLEEP
Do you every experience difficulty falling asleep? YES
If yes, how often?_______________per week
_______________per month
At what time do you typically go to bed?
On weekdays (Sun-Thurs) ______________AM
On weekends (Fri-Sat)
______________AM
NO
PM
PM
At what time to you typically awaken?
On weekdays (Mon-Fri)
______________AM
PM
On weekends (Sat-Sun)
______________AM
PM
Do you often read or watch TV in bed before going to sleep? YES
NO
If yes, for how long to you typically engage in this activity before you decide to go to sleep:
_________________________________________
Once you decide to go to sleep, how long does it typically take you to fall asleep at night:
On weekdays (Sun-Thurs) _______________Minutes/hours
On weekends (Fri-Sat)
_______________Minutes/hours
While falling asleep do you:
Often notice that parts of your body startle or jerk
YES
NO
Sometimes experience vivid dream-like scenes though
you know that you are awake (i.e., hallucinations)
YES
NO
Often have thoughts racing through your mind
YES
NO
Often feel sad or depressed
YES
NO
Often have anxiety (worry about things)
YES
NO
Often feel afraid of not being able to sleep
YES
NO
Often feel frustrated by an inability to sleep
YES
NO
Often feel muscular tension
YES
NO
Often experience “restless legs” (an uncontrollable
urge to move or exercise your legs to relieve leg
discomfort)
YES
NO
Often experience pain or physical discomfort
If “YES” describe:
YES
NO
Often fall asleep in less than 5 minutes
YES
NO
Often take more than 30 minutes to fall asleep
YES
NO
DURING SLEEP
How often do any of the following occur during sleep?
Talk
ALWAYS
OFTEN SOMETIMES
SELDOM
RARE NEVER/NOT KNOWN
Walk
ALWAYS
OFTEN SOMETIMES
SELDOM
RARE NEVER/NOT KNOWN
Kick
ALWAYS
OFTEN SOMETIMES
SELDOM
RARE NEVER/NOT KNOWN
Snore
ALWAYS
OFTEN SOMETIMES
SELDOM
RARE NEVER/NOT KNOWN
Make odd ALWAYS
movements
OFTEN SOMETIMES
SELDOM
RARE NEVER/NOT KNOWN
Wet the bed ALWAYS
OFTEN SOMETIMES
SELDOM
RARE NEVER/NOT KNOWN
Grind teeth ALWAYS
OFTEN SOMETIMES
SELDOM
RARE NEVER/NOT KNOWN
Fall out
of bed
OFTEN SOMETIMES
SELDOM
RARE NEVER/NOT KNOWN
ALWAYS
How did you first know of these behaviors?___________________________________________________
______________________________________________________________________________________
How many hours of actual sleep do you get on a typical night?______________________
How many times do you typically awaken during the night?________________________
Why do you awaken during the night?_________________________________________
When you awaken during the night, how long does it typically take for you to return to sleep?
____________________________Minutes/hours
What is the total time you are awake during the night?_________________________
On a typical night, is your sleep disturbed by any of the following?
Asthma
Persistent cough
Regurgitation
Panic
Heartburn
Difficulty breathing
Need to urinate
Nasal congestion
Sweating
Heart pounding
Headache
Muscle cramps
YES
YES
YES
YES
YES
YES
0 1 2 3 4
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
5/times per night
NO
NO
NO
NO
NO
Nightmares
YES
Thrashing movements
YES
Racing thoughts, worries YES
Restless legs/need to move YES
Noises in sleep area
YES
Child/pet care needs
YES
Choking or need for air YES
Bed partner
YES
Heat or cold
YES
Light in sleep area
YES
Uncomfortable sleep
YES
surface
Hunger or thirst
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
Do you consider yourself a LIGHT, NORMAL or HEAVY sleeper? (circle one)
MORNING
Do you have difficulty awakening in the morning? YES
NO
Are you often confused, disoriented, or violent upon awakening in the morning? YES
NO
Have you ever been unable to move (paralyzed) for several seconds (10-30) upon awakening in the morning?
YES
NO
Do you cough up sputum in the morning?
YES
Do you often wake up with a morning headache?
NO
YES
NO
Need an alarm clock to wake you up?
If yes, do you use the “snooze” button
to get a few extra minutes of sleep?
YES
YES
NO
NO
Immediately feel refreshed?
YES
NO
Need coffee or a shower to feel alert
YES
NO
Often have a dry mouth
YES
NO
Often have a sore throat
YES
NO
In the morning when it is time to get up, do you:
DAYTIME FUNCTIONING
Is daytime sleepiness currently a problem for you?
YES
NO
If yes, describe what activities does it interfere with_____________________________________________
______________________________________________________________________________________
You are most alert at ____________________AM
PM
You are least alert at____________________AM
PM
Do you sometimes take naps (5 minutes or more in duration)? YES
NO
How many times per month do you nap?_____________________________________________
Do you feel refreshed by these naps?________________________________________________
During the past 6 months, have you fallen asleep OR had to fight sleepiness (i.e., struggled to stay awake) in the
following situations:
While eating food
During intercourse
Talking on the phone
In conversations at work
In other conversations
At meetings
Talking in groups (i.e., with guests at home)
While driving a motor vehicle
Riding as a passenger (car, train, etc)
Attending a lecture or performance
Reading a book (not in bed)
Listening to music
Watching television
At the movies
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
Have you fallen asleep in other inappropriate settings in the past few months? YES
NO
If yes, please describe____________________________________________________________________
______________________________________________________________________________________
Do you ever discover that you have performed some complex act such as driving a car to the wrong destination and
not remember doing it? YES
NO
Do you every find yourself doing things that make no sense (writing nonsense or mixing chocolate with gravy, etc)?
YES
NO
Have you ever experienced muscle weakness in strong emotional situations (i.e., during laughter, rage, etc).
Yes
NO
Have you ever fallen limp to the ground when excited (without fainting or losing consciousness)?
Yes
NO
What is your personal interpretation as to why you have your particular sleep/wake problem?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
MEDICAL HISTORY
Allergies______________________________________________________________________________
List medications that you use (prescription and over the counter)
______________________________________
___________________________________________
______________________________________
___________________________________________
______________________________________
___________________________________________
Do you have epilepsy or seizure disorder?
YES
NO
Have you ever had a head injury?
YES
NO
Do you suffer from dizzy spells?
YES
NO
Do you frequently faint?
YES
NO
If yes, give date_______________________
Have you had a significant change in body YES
NO
weight?
If yes, weight GAIN or LOSS (circle one) over what period of time?_______________________________
Please list current or previous medical problems, with special attention to lung, heart, psychiatric, or nervous system
disorder:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
List all past surgical procedures and dates:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
SOCIAL HISTORY
Do you or did you smoke?
YES
NO
If yes, how much________________________________________________
How often to you smoke within 2 hours of bedtime?____________________
Do you drink alcohol?
YES
NO
If yes, how much to you typically drink?______________per day _________________per week
How many caffeinated beverages do you drink (coffee, tea, caffeinated soft drinks)?
_____________________________________________________________________
Please list recreational substances that you have used:
_____________________________________________________________________
What is your present occupation?__________________________________________
What hours to you work?________________________________________________
Have you ever worked on a rotating shift? YES
NO
If you have worked a rotating shift, describe the job including hours of each shift, how often you were required to
shift, and the dates of your employment.
_____________________________________________________________________________________
_____________________________________________________________________________________
How often to you engage in exercise?_________________________________________per week or month
What do you do for exercise?_______________________________________________________
At what time of the day do you exercise?______________________________________________
How long is a typical exercise session?_______________________________________________
FAMILY HISTORY
Any blood relatives with sleep related problems?
YES
NO
If yes, describe the problem:_______________________________________________________________
______________________________________________________________________________________
Do any blood relatives have epilepsy or seizure disorder?
YES
NO
DEVELOPMENTAL HISTORY
As a child (up to age 16) did you have a problem with:
Getting to sleep at night
YES
NO
Waking up in the morning
YES
NO
Waking during the night
YES
NO
Sleepiness during the day
YES
NO
Were you born as part of a multiple birth:
YES
NO
What was your birth weight?______________________
Were there any unusual conditions of pregnancy or delivery (prolonged labor, forceps, blue baby, etc.)
YES
NO
If yes, describe:_________________________________________________________________________
______________________________________________________________________________________
If your sleep/wake behavior is not adequately covered by the above questions, briefly describe the nature of your
sleep/wake problem and list anything else that interferes with your sleep or wakefulness:
IMPORTANT!!! PLEASE MAKE SURE THAT YOU HAVE ANSWERED ALL QUESTIONS FULLY