SoFHA
Patient Forms

Annual PAP Follow Up

Description:

The SoFHA Sleep Center Annual PAP Follow Up paperwork.

Code:

9.106

Issued:

12/19/2019

Revision:

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.

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Interpreter Services

Patient Information

Name First, MI, Last

Date of Birth

Address Line 1

Address Line 2Optional

City

State

Zip Code

HeightOptional

WeightOptional

Neck SizeOptional

Gender

Marital Status

Home Phone

Cell Number

Work Number

EmployerOptional

OccupationOptional

Insured Information

Relationship to Insured

Insured's Name If not patient

Insured's Social Security

Insured's Date of Birth

Physician Information

Primary Physician

Phone

Specialty

Referring Physician

Phone

Specialty

Sleep Schedule

Work Hours

Work Shift

Weekday

Bedtime

Wake Time

Average amount of sleep per night

Weekend

Bedtime

Wake Time

Average amount of sleep per night

Time it takes to go to sleep

Times per night you wake up

Do you fall back to sleep easily?

What wakes you from your sleep?

Do you nap?

Epworth Sleepiness Scale

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

Sitting and Reading

None

Slight

Moderate

High

Watching TV

None

Slight

Moderate

High

Sitting inactive in a public place (Theater or Meeting)

None

Slight

Moderate

High

As a passenger in a car for an hour without a break

None

Slight

Moderate

High

Lying down to rest in the afternoon

None

Slight

Moderate

High

Sitting and talking to someone

None

Slight

Moderate

High

Sitting quietly after a lunch without alcohol

None

Slight

Moderate

High

In a car, while stopped for a few minutes in traffic

None

Slight

Moderate

High

PAP Treatment

Are you currently using a PAP device?

Yes

Pap Benefits

Reasons for Limited Use

Current Symptoms

Snoring

Daytime Sleepiness

Frequent Arousals

Night Sweats

Insomnia

Nighttime Urination

Restless Legs

Nightmares

Fatigue

Current Medications

Pharmacy Name and Location

Current Medications

Are you currently using or have used oxygen at home?

Yes

DME Company

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.

Patient Signature