Please check all the boxes that CURRENTLY apply to you:
Have you ever had any of the following medical conditions? Check all that apply.
For the following situations, indicate the chance of dozing or falling asleep (not feeling tired) by using the scale below:
0 = Would never doze
1 = Slight chance of dozing
2 = Moderate chance of dozing
3 = High chance of dozing
Mark the most appropriate box:
Never = It does not occur Occasionally = Occurs one or more times a week
Rarely = Occurs monthly Frequently = Almost daily
I hear by give permission to Texas Sleep Medicine to release my medical records to the above providers. This information may be disclosed by fax, by mail, or by oral communication. I understand that my records are protected and cannot be disclosed without this written consent. I also understand that I may revoke this consent by written communication except to the extent that action has already been taken in reliance on it (i.e. information already disclosed My signature means that I have read this form and/or have had it read to me and explained in the language that I can understand. This authorization shall remain valid until revoked by me in writing.