SoFHA
Patient Forms

Patient Paperwork


Description:

The SoFHA Sleep Center new patient paperwork.


Code:

9.001

Issued:

04/12/2019

Revision:

1

Revised:

N/A

It is important that you fill out this sleep questionnaire completely and as accurately as possible. Please answer each question. The questionnaire is a broad-based screening tool that will assist our staff and your treating sleep physician to provide excellent care to you. It may be helpful to consult with a family member or bed partner when answering these questions. All information contained in this questionnaire will become a part of your medical record and will be confidential.

Directions to Our Office

Notice of Nondiscrimination

Interpreter Services


Patient Information



















Insured Information







Physician Information









Reason For Visit


How long have you had this problem?





Sleep Schedule




Weekday






Weekend










What wakes you from your sleep?




Epworth Sleepiness Scale

Please estimate your risk of falling asleep in the following situations.


Medical History


Social History







PAP Treatment


Family History

Which blood relatives been diagnosed with the any of the following:







Current Medications





Signature

By typing your name in the signature fields below, you consent to all of the agreements listed in this form. You furthermore agree that your submission of this form, via the "Submit Form" button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.