Patient Health History

Patient Health History

Sleep Medicine Patient History Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Allergies to Medications:*

YesNo
If yes, please identify medication name and reaction:
List Medications and Dosage

(Please include inhalers, nebulized treatments, patches, herbalsupplements, over the counter meds & vitamins)

Medical History

Please check all medical conditions you have been treated for
Select all that applies*

HypothyroidismAtrial FibrillationAnxietyAsthmaBack painHeart Disease (coronary artery disease)CancerCOPD (Chronic Obstructive Pulmonary Disease)Stroke (CVA-Cerebral Vascular Accident Stroke)DVT (Deep Vein Thrombosis)DepressionDiabetes Type 1Diabetes Type 2FibromyalgiaGERD (Gastroesophageal Reflux Disease)Head InjuryPE (Pulmonary Embolism)High CholesterolExcessive Daytime SleepinessHigh Blood PressureInsomniaIron Deficiency AnemiaNarcolepsyOsteoarthritisOSA (Obstructive Sleep Apnea)ParasomniaRestless Legs SyndromeRheumatoid ArthritisSeasonal AllergiesSeizure DisordersShift Work Sleep Disorder
Please list any other conditions you have been treated forthat are not included above:
Family History

Please check if anyone in your family (not including yourself) have or have had any ofthe following
Unknown Family HistoryAdopted

If yes, please provide following information

	# of packs	# of years	Year quit (if applies)
Former Smoker
Current Smoker

Alcohol
Type*

Do not drinkBeerWineHard Liquor
Drinking habits (if applies)

Occasional (few times a month)Light: less than 2 per dayModerate: 2-3 per dayHeavy: 4 or more per day
Caffeine-Daily Intake
Do you drink caffeinated beverages?*

YesNo

If yes, please provide following information

What time do you stop drinking caffeine?
Living Situation*

Married, living with spouseSingle, live aloneSingle, living with significantotherSingle, living with familyDivorcedWidowedNursing home/Grouphome/Asst living
Employment Status*

Full-timePart-timeUnemployed looking for workUnemployed not looking for workDisabledRetired
If employed, Occupation and hours work/shift
If disabled, reason for disability
Past Surgeries

Please check all that apply and enter year of surgery as applicable
Select all that applies*

Adenoids removedAppendixBack SurgeryBariatric SurgeryBunionectomyCardiac AblationCardiac CatheterizationCardiac StentsPacemaker/Defibrillator implantCardioversion ElectricCarpal Tunnel ReleaseRotator CuffCesarean DeliveryGall Bladder RemovalCoronary Artery bypass GraftFoot SurgeryHysterectomyHernia RepairJoint ReplacementSinus SurgeryThyroid SurgeryTonsils RemovedTubal LigationVasectomy
If Bariatric Surgery, what type?
If Cardiac Stents, how many?
If Foot Surgery, what type?
If Hernia Repair, select the appropriate option

UmbilicalInguinalRightLeft
If Carpal Tunnel Release, select the appropriate option

LeftRightBoth
If Joint Replacement, select the appropriate option

LeftRightBoth
If Rotator Cuff , select the appropriate option

LeftRightBoth
Please list any other surgeries or hospitalizations not included above and year:
Should be Empty:

List Medications and Dosage