MOBILE SLEEP SERVICES, INC.
8668 West Glasgow Place
Littleton, CO  80128
Phone: (303) 932-2243             FAX: (303) 932-6422
www.mobilesleepservices.com	Last Name:  ______________________________

First Name:  ______________________________

Date of Study: ______/______/______             	

Date of Birth: _____/_____/_____     Sex:  ___Male  ___Female     

PLEASE ANSWER THE FOLLOWING QUESTIONS REGARDING YOUR TYPICAL SLEEP HABITS AND DAILY ROUTINE
If possible, please fill out this questionnaire with your bed partner.  Please use the space provided beside the question and/or at the end of this questionnaire to elaborate on any questions if necessary.  For those questions with any of the letters (Y  S  N) in the left hand column, please circle the appropriate answer using the following guidelines:          Y = Yes          S = Sometimes          N = No          

      SLEEP HISTORY	
	What is your sleep complaint/reason for this study?	
Y         N    	Have you ever had a sleep study before?	
	If yes:	Where:	When:	Diagnosis:	
		Any changes since last study?  N   Y   __Weight loss(_____lbs)  ___Surgery  __Other:	
		If Surgery:  	__UVPP  __Septoplasty  __Tonsilectomy  __Gastric Bypass  __Other:	
Y    S     N	Are you currently on supplemental oxygen?    	If yes, how much (LPM):                                                  __Don't Know	
	If yes:	How often:  __24/7  __Only while sleeping  __On exertion  __As needed  __Other:	
Y            N    	Have you ever been prescribed (check all that apply):     ____CPAP   ____BiPAP      	
	If yes:	Y  S  N	Are you currently using this therapy?	What is your current setting:                  __Don't Know	
		Y  S  N	Do you use oxygen with your PAP therapy?	How much (LPM):                                  __Don't Know	
	
EPWORTH SLEEPINESS SCALE
Please use the following scale to note your likelihood of dozing off in the following situations:  0 = Never  1 = Slight  2 = Moderate  3 = High	
Sitting and reading ______ 	Watching TV ______	As a passenger in a car for one hour ______	
Sitting in a public place like a meeting or class room ______	Lying down to rest in the afternoon ______	
Sitting and speaking to someone ______	Sitting quietly after lunch (without alcohol) ______	
In a car stopped for a few minutes in traffic ______	______/24	
	
SLEEP/WAKE PATTERN	
	Normal bedtime:	Normal wake time:	Hours in bed:	
	How many times do you usually wake at night:	What usually wakes you up?	
	How do you feel you usually sleep at night?      ____Poor         ____Average      ____Good	
	How do you usually feel in the morning?            ____Tired        ____Rested        ____Wide Awake	
	How do you feel the rest of the day?                   ____Tired        ____Rested        ____Wide Awake	
	What is your usual sleep position?  ___Back    ___Left    ___Right    ___Stomach   ___Recliner   ___Other:	
	How was last night’s sleep compared to a typical night of sleep for you?     ____Worse     ____Same     ____Better	
Y    S     N	Is your bedroom completely dark?	
Y    S     N	Do you sleep on a regular schedule?	
Y    S     N	Do you have a hard time getting to sleep?	
Y    S     N	Do you wake up and can’t get back to sleep?	
Y    S     N	Do you have trouble concentrating during the day?	
Y    S     N	Do you work different shifts?	
Y    S     N	Do you have thoughts racing through your mind while trying to get to sleep?	
Y    S     N	Do you get up at night to eat and/or drink?    If yes, how much:	
Y    S     N	Have you ever fallen asleep while driving?     If yes, how often has this occurred?	
	
NAPS	
Y    S     N	Do you take naps?  (If no, continue on to next section of the questionnaire.)	
	IF YES	How many naps do you take?     	On a typical weekday:	On a typical weekend day:	
		How long are these naps?           	On a typical weekday:	On a typical weekend day:	
		Y    S     N	Do these naps improve your alertness the rest of the day?	

1	
	MOBILE SLEEP SERVICES, INC.
8668 West Glasgow Place
Littleton, CO  80128
Phone: (303) 932-2243             FAX: (303) 932-6422
www.mobilesleepservices.com	Last Name:  ______________________________

First Name:  ______________________________

Date of Study: ______/______/______             	
	
SLEEP DISORDERS	
Y    S     N	Have you been told that you snore?	
Y    S     N	Have you been told that you stop breathing when asleep?	
Y    S     N	Do you wake up choking at night?	
Y    S     N	Have you been told or have you felt your legs twitch/jerk at night?	
Y    S     N	Do your legs feel restless?	
Y    S     N	Do you sweat during the night?	
Y    S     N	Do you wake up with a stomach acid taste in your mouth?	
Y    S     N	Do you feel like you can’t move when falling asleep?	
Y    S     N	Do you feel like you are dreaming when falling asleep?	
Y    S     N	Do you feel weak or even fall to the ground while laughing or with other strong emotions?	
	
HEADACHES / ACHES / PAINS	
Y    S     N	Do you get headaches during the night?	
Y    S     N	Do you get headaches when you get up in the morning?	
Y    S     N	Do you suffer from Migraines?	
Y    S     N	Do you have aches and pains all the time?	
	
NASAL/ORAL CONDITIONS	
Y    S     N	Do you have nasal congestion such as allergies?	
Y    S     N	Do you have difficulty breathing through your nose?	
Y    S     N	Do you have nasal blockage such as a deviated septum?	
	If yes and if known, what is the blockage?	
	
CAFFEINE USE	
Y    S     N	Do you drink and/or eat any caffeinated foods or beverages?  (If no, continue on to next section.)	
	IF YES	If yes, how much of the following caffeinated items do you typically consume on a daily basis? 	
		__Coffee	How Much?	When:	
		__Tea	How Much? 	When:	
		__Soda	How Much? 	When:	
		__Chocolate	How Much? 	When:	
		Y    S     N	Do you drink more than 4 cups/cans of caffeinated beverages a day?	
		Y    S     N	Do you eat and/or drink any caffeinated foods or beverages after noontime?	
	
TOBACCO USE	
Y    S     N	Do you currently or have you ever used a tobacco product?  (If no, continue on to next section.)	
	IF YES	What product?  __Cigarettes  __Cigars  ___Chew	How much per day?	
		Y    S     N	Do you still use tobacco products?  	If yes for how long?	
		IF NO	How long ago did you quit?                        	
			How long did you use tobacco products?	
	
ALCOHOL USE	
Y    S     N	Do you drink alcohol (beer, wine, distilled liquor, etc.)? (If no, continue on to next section.)	
	IF YES	What:	How much:	How Often:	
		What is the maximum at one time?	
		Y    S     N	Do you use alcohol to help you sleep at night?	

2
	MOBILE SLEEP SERVICES, INC.
8668 West Glasgow Place
Littleton, CO  80128
Phone: (303) 932-2243             FAX: (303) 932-6422
www.mobilesleepservices.com	Last Name:  ______________________________

First Name:  ______________________________

Date of Study: ______/______/______             	
	
MEDICAL CONDITIONS 
(Please Check All That Apply)	
__Diabetes	__Heart Disease	__Respiratory Problems	__COPD	
__Depression	__High Blood Pressure	__Asthma	__Chronic Heart Failure	
Please list any other medical conditions you have:	
	
Please list any surgeries you have had:	
	
SLEEP MEDICATION	
Y    S     N	Do you take sleeping pills?  If yes, name of medication(s):	
PRESCRIBED AND OVER THE COUNTER (OTC) MEDICATIONS PLUS SUPPLEMENTS	
Y            N    	Do you have a list of medications to give to the technician?	
	IF YES	Please give the list to the technician so they can copy it for our records. 

You do not need to repeat your medications below unless there are medications not noted on your list.	
	IF NO	Please list below all of the prescribed and OTC medications plus supplements you currently take. 	
MEDICATION	DOSAGE	REASON PRESCRIBED	TIME TAKEN	

				

				

				

				

				

				

				

ADDITIONAL COMMENTS	

	

Patient/Guardian Signature: _______________________________    Date: _____/_____/_____      Tech Initials: _____ 

                                                                                                                                                                                                   Template Revised:  08/15/15      
3        

	MOBILE SLEEP SERVICES, INC.
8668 West Glasgow Place
Littleton, CO  80128
Phone: (303) 932-2243           FAX: (303) 932-6422
www.mobilesleepservices.com	Last Name:  ______________________________

First Name:  ______________________________

Date of Study: _____/_____/_____             	

WHAT TO EXPECT DURING YOUR STUDY
Your physician has ordered a sleep study for you.  This form is used to ensure that you understand the procedure that is about to be performed and that any questions about this procedure have been answered.  Please make sure you understand the procedures listed below.  If not ask the technician to explain any procedure you don't understand.  Your physician, who ordered this sleep study, still has control over your treatment.  Mobile Sleep Services, Inc. is just providing the sleep study test.  Any questions you may have regarding the outcome of this test and/or treatment should be addressed to your physician.  If treatment with nasal CPAP/BiLevel and/or oxygen is ordered by your physician, then your follow-up will be done with your physician and the home healthcare company you select.  Your physician already knows that if he has any questions about your treatment he can contact the physician who read the sleep study.

Electrodes will be taped or pasted to your head, face, chin and behind your ears to measure sleep stages and other indicators of sleep.  None of these electrodes will be inserted into the skin itself.  Electrodes will be taped to your chest and side to measure your heart activity during sleep.  Electrodes will be taped to your legs to see if your legs jerk or move while you sleep.  Two sensors will be taped to your upper lip to measure nasal/oral airflow and bands will be placed around your chest and abdomen to measure effort.  A monitor will be placed on your finger which will shine a light through the finger to indicate how much oxygen is carried in the blood.  All of these electrodes combined indicate how well you sleep, how well you breathe, if you have enough oxygen during the night and if leg jerks or other problems are waking you up during the night.  Although we try to use electrodes and tape that people are not usually allergic to, some people may still develop red areas from where the tape and electrodes were placed.  These red areas will eventually fade away within a few hours from the end of the test. 
Nasal CPAP is a machine, attached to a mask, which is placed over your nose.  Air is sent through the nose to act like an air-splint on the back of your throat.  This form of therapy is used primarily to treat you for obstructive sleep apnea or hypopnea (these conditions will be explained by the technician).  Nasal BiPAP is similar to CPAP except you inhale at a higher pressure than you exhale.  If ordered by a physician, oxygen may be started and adjusted to maintain proper oxygen levels at night.  If you are already on oxygen, it may be adjusted to obtain optimal oxygen levels.
Keep in mind that only a physician can diagnose and decide treatment for a patient's condition.  Comments made by the technician are to help you understand why certain things are being done, but may not necessarily be your final mode of treatment.  Information gathered by the technician is passed on to the physician to help in his interpretation.  Please wait for the formal interpretation of your sleep study.
The sleep study will be done in a hospital/clinic setting.  That hospital/clinic’s normal emergency procedures will be followed.  If an emergency occurs during the night of your sleep study, the technologist is trained in CPR. 
PRIVACY STATEMENT AND
CONSENT TO DIAGNOSTIC PROCEDURE AND RELEASE OF MEDICAL INFORMATION
New regulations are in effect as of April 14, 2003 that further protects the information you provide when pursuing medical care.  Mobile Sleep Services, Inc will adhere to these guidelines that further protect the personal, medical and insurance information we collect.  Only information needed to perform your sleep study will be collected. 
I understand the hospital will bill my insurance company and/or myself for the cost of the sleep study.   Mobile Sleep Services, Inc. bills the hospital for its services; you will not receive a bill from us.  Billing information is collected for the physician who will read your sleep study.  The physician who interprets the sleep study will bill your insurance separately for this service.  I understand that I will be responsible for any monies owed to the hospital or interpreting physician if my insurance denies payment. 
I understand the above procedures and give my consent to have the above procedures and conditions.  I further consent to release my sleep study records generated and collected by Mobile Sleep Services, Inc. to: the physician who ordered the sleep study, the physician who will read the sleep study, the hospital/clinic where the sleep study was performed and to my home healthcare provider if requested.  A copy of your sleep study may be obtained from either your physician, the hospital/clinic where your sleep study was done or from Mobile Sleep Services, Inc.  This is to further protect your information.  
I understand that I have the right to refuse the release of my personal, medical and/or insurance information and I waive this right by not signing this consent.  In refusing to sign, I realize the sleep study cannot be performed and that all information submitted to initiate the sleep study to this point will be destroyed. 
Acceptance: The undersigned certifies that he/she has read this agreement and consent; understands its contents; is the patient, or person duly authorized by; the patient or otherwise to execute this agreement and consent to accept its terms.
I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made as to the results of the test(s) or procedure(s) specified above. 
PATIENT’S NAME (Please Print):  ____________________________________________________________________________________________ 
PATIENT/GUARDIAN SIGNATURE: ___________________________________________________________________      Date: _____/_____/_____
VIDEO/PHOTOGRAPH CONSENT AND RELEASE
     I hereby consent to my video/photograph being taken for medical documentation and irrevocably authorize the Mobile Sleep Services, Inc. its successors and assigns, and those acting with its permission and upon its authority to photograph, videotape or film for motion pictures any depiction or likeness of me or in which I may be included in whole or in part.  I understand that this video/photograph is a necessary and integral part of my diagnostic procedure.  Any such photograph, videotape or film will be kept as part of my medical records generally, and will be released only pursuant to my consent or in accordance with other appropriate procedures for release of medical information. 

PATIENT’S NAME (Please Print):  ____________________________________________________________________________________________ 
PATIENT/GUARDIAN SIGNATURE: ___________________________________________________________________      Date: _____/_____/_____
Template Revised 08/15/15