Download New Patient

Johns Hopkins Center for Sleep
Patient Intake Form
Leave blank for label
What is the reason you are here today? ________________________________________________________________
Social History (circle):
Single / In a relationship / Married / Divorced / Widowed
Do you have a bed partner?
Yes No
Have you been in an accident or driven off the road because of feeling drowsy?
Yes No
Are you currently at your highest weight for your lifetime?
Yes No
Have you had weight loss surgery?
Yes No
I am interested in participating in potential research studies and would like to be contacted.
Yes No
I give permission for my sleep center data to be used for research.
Yes No
REVIEW OF SYMPTOMS – Please check all those that apply based on symptoms over the last month.
Pain Rating (now) _______ (0-10)
o Dizziness
o Diarrhea
o Fatigue or tiredness
o Headaches
o Constipation
o Overly sleepy
o Difficulty with
o Stomach problems
o Fever
memory/concentration
o Sour taste
o Chills
o Changes in your mood
o Belching
o Night sweats
o Changes in your behavior
o Reflux
o Hot flashes
o Claustrophobia/Anxiety
o Leg cramps
o Chest pain
o Seasonal allergies
o Joint pains ________ (0-10)
o Swelling in feet
o Nasal congestion
o Back pains ________ (0-10)
o Swelling in legs
o Runny nose
o Rash
o Blood in urine
o Shortness of breath at rest
o Excessive thirst
o Blood in stools
o Shortness of breath with activity
o Weight gain
o Frequent urination
o Cough
o Other ___________________
Epworth: How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This
refers to your usual way of life in recent times. Even if you haven’t done some of the activities recently, think about
how they would have affected you. Use this scale to choose (circle) the most appropriate number for each situation:
1 = slight chance of dozing
3 = high chance of dozing
Sitting and reading
Watching TV
Sitting inactive in a public place
Being a passenger in a motor vehicle for an hour or more
Lying down in the afternoon
Sitting and talking to someone
Sitting quietly after lunch (no alcohol)
Stopped for a few minutes in traffic while driving
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
Score
__________
Patient Signature: ____________________________________________________ Date & Time: __________________
(OVER)
General Instructions for all Sleep Patients
Your Doctor thinks you may have sleep apnea, what happens next - Your Doctor orders a sleep study (polysomnogram)
to determine if you have sleep apnea.
You will contact the sleep lab to schedule an appointment for an overnight sleep study at 1-800-WE SLEEP or 1-800-9375337
You may schedule a visit with your Doctor following the sleep study to review your results and to discuss your options. In
many cases, to get you treated sooner, your Doctor may order a second sleep study (a titration study) and then
continuous positive airway pressure (CPAP) for home use. Your Doctor will review the results in detail at your next
office visit and discuss the next steps.
What to expect after my titration study:
 The results of your study will be mailed to you and faxed to the Doctor who referred you
within 10-14 business days
 When the PAP device is ordered by your Doctor the order will be sent to a DME (durable medical equipment)
company that will provide your CPAP/BIPAP equipment
 The DME company will then contact you to set up an appointment to receive your equipment
 You will make a follow up appointment with your Doctor 4-6 weeks after starting CPAP/BIPAP therapy. Please
call 410-730-1988 to make your appointment.
About the sleep study:
What to bring – comfortable pajamas. Please do not bring pillows/blankets from home.
We use sticky paste to keep the electrodes on the head during the study - Any residue from the study will clean up
easily with a hot shower or bath and hair shampoo. We recommend not scheduling your sleep study appointment near
any hair styling changes.
Activity - Do not operate a motor vehicle or heavy machinery if you feel sleepy or fatigued. The sleep test lasts about 6
½ hours so that may not be enough sleep to make you feel rested. You may wish to make alternative plans for
transportation home after completing a procedure. Please let our staff know if you are feeling too sleepy to drive home.
Medication - Continue medication routines as directed by your health care provider
Discomfort from a sleep study procedure - There should be no pain or discomfort after a sleep study. In rare instances,
an allergic reaction to the adhesives used may occur. Please contact your primary care or sleep medicine physician
immediately for instructions or additional medications if you have persistent swelling, redness, rash, itching, or pain in
areas where adhesive or tape have been applied.
Thank you for choosing to come to the Johns Hopkins Center for Sleep for your sleep testing. If you have any questions,
please contact us at 1-800 WE SLEEP