| Sleep Questionnaire pages 4-6 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Name: ___________________________________________________ Date: _________________ Circle any of these symptoms/problems that are current concerns: Headache Seizure Stroke Balance Mobility Strength Vision Hearing Nasal Allergies Other allergies Sinus Infection Nasal Obstruction TMJ pain Dental Voice Cough Short breath Chest pain High blood pressure Heart disease Congestive heart failure Edema (swollen extremities) Swallowing Indigestion Heartburn Liver disease Diarrhea Prostate problem Kidney Disease Menopause Arthritis Muscle disease Osteoporosis Fibromyalgia Chronic skin condition Diabetes Thyroid Other Hormonal Chronic pain Cancer Weight loss Depression Anxiety Other psychiatric Please list all medication (prescription or OTC) used now or in the past for sleep: MEDICATION FOR SLEEP Dose Times daily Use now? Provider ________________________ ______ ______ ____________ _______ _____ __________ _____________________ ________________________ ______ ______ ____________ _______ _____ __________ _____________________ ________________________ ______ ______ ____________ _______ _____ __________ _____________________ ________________________ ______ ______ ____________ _______ _____ __________ _____________________ ________________________ ______ ______ ____________ _______ _____ __________ _____________________ ________________________ ______ ______ ____________ _______ _____ __________ _____________________ ________________________ ______ ______ ____________ _______ _____ __________ _____________________ Please list all other medications that you are currently taking (or provide a list): CURRENT MEDICATION Dose Times daily AM/PM Provider ________________________ ______ ______ __________________________ __________ _____________________ ________________________ ______ ______ __________________________ __________ _____________________ ________________________ ______ ______ __________________________ __________ _____________________ ________________________ ______ ______ __________________________ __________ _____________________ ________________________ ______ ______ __________________________ __________ _____________________ ________________________ ______ ______ __________________________ __________ _____________________ ________________________ ______ ______ __________________________ __________ _____________________ Name: ___________________________________________________ Date: _________________ FAMILY HEALTH HISTORY: For blood relatives, indicate gender, vital status, major health problems, and any sleep disorder; for aunts, uncles, cousins only record conditions that may affect you. Gender Living or Major Health Problem Sleep Disorder Deceased
Primary Care Physician Referring Physician (if not your Regular Physician) Name: ______________________________________ ________________________________________ Address: ______________________________________ ________________________________________ ______________________________________ ________________________________________ ______________________________________ ________________________________________ Use the space below for additional comments that you may wish to make. _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ |
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