* = Required Information
First Name *   Middle Name   Last Name * Age:   Weight: Lbs.   Height: Ft.   in.   Neck Girth: in.   Handed: Right Left Occupation: Education: High school GED College PhD/Masters Referring Physician: *
History of Present Illness: What is the reason for your visit? When did symptoms start? Does it occur daily, weekly, monthly or randomly? What is the location of the symptoms? Does it involve any other body part? What makes it worse? What makes it better? How do you rate your symptoms? (0- none, 10- worst ever) Are your symptoms related to injury at work or due to an automobile accident Yes No How do the symptoms affect your daily activities at home and work? Have you tried any medications (over the counter or prescribed)? Recent test or ER/Hospital information (CT, MRI, Blood work, EMG, EEG, Sleep Study): CAP Trial : Do you have any of the following symptoms at PRESENT TIME: Headache Visual change Nausea/ Vomiting Dizziness/ Vertigo Difficulty swallowing Difficulty speaking Memory problems Tremors Hearing problems Seizures Falls Passing out Snoring Daytime sleepiness Fatigue Restless legs Muscle Stiffness Hand/Arm pain Neck pain Foot/ leg pain Low back pain Hand weakness Tingling/ Numbness Difficulty walking Incontinence
Past Medical History: Hypertension Diabetes High Cholesterol Weight gain / Obesity Heart disease/ CHF COPD/ Emphysema Stroke Brain tumor/ Aneurysm Bleeding disorder Cancer Stomach Ulcer Depression/ Anxiety Liver disease Kidney disease Hypothyroidism Vitamin Deficiency Anemia Hepatitis B/C Other HIV Positive
Past Surgical History: (Please list all surgeries and dates): Brain Neck Back Heart/Bypass/Stent Carotid Tonsillectomy Knee Deep Brain Stimulation Vagal Nerve Stimulation Gall Bladder Removal Hysterectomy Gastric Bypass/Lap band Others
Family History: (State the health information of the following family members) Parents: Siblings: Children: Grand-Parents: Extended Family: Are you adopted: Yes No   Does any hereditary disorder run in your family?
Social History: Tobacco: Never Smoked Former Smoker Current every day Smoker Alcohol: Do not Drink Occasional/Social Drinker Heavy Drinker Used to drink Illicit Drugs: Do you take drugs? Yes No Caffeine: Coffee Tea Soda How many cups a day? Where do you live? Private residence Assisted Living Nursing Home- Who do you live with?
Allergies: (Medications & Food): Yes No
Medications: (List all medications – prescribed and over the counter- with dosage) Do you take Aspirin or other Anti-platelet medication? Yes No
Review of System: Please choose any problems that are present at present? Fever chills night sweats Weight gain weight loss Bleeding bruising Hearing problems Vomiting Double vision blurry vision Palpitation Chest pain Shortness of breath Constipation Diarrhea Nausea Urinary incontinence Anxiety Depression Skin Rash Sexual complaint Joint Pains
Epworth Sleepiness Scale: How likely are you to doze off or fall asleep in the following situations? 0- would never doze, 1- Slight chance of dozing, 2- Moderate chance of dozing, 3- High chance of dozing. Sitting and Reading 0 1 2 3 Watching Television 0 1 2 3 Sitting inactive in a public place (theatre) 0 1 2 3 As a car passenger for an hour without break 0 1 2 3 Lying down to rest in the afternoon 0 1 2 3 Sitting and talking to someone 0 1 2 3 Sitting quietly after lunch without alcohol 0 1 2 3 In a car, while stopping for few minutes in traffic 0 1 2 3 Total
Sleep Environment: What time do you sleep on weekdays? What time do you sleep on weekends? What time do you wake up on weekdays? What time do you wake up on weekends? Average number of awakenings during sleep: Do you read in Bed? Yes No Do you carry work to bed? Yes No Do you watch TV in bed? Yes No Does your bed partner have sleep problems? Yes No Do you nap in daytime, If yes, how long? Yes No Trouble falling asleep: Yes No Trouble staying asleep: Yes No Snoring: Yes No Your Breathing stops at night: Yes No Wakes up to pass urine at night: Yes No Have Heartburns at night: Yes No Have Leg kicking at night: Yes No Have Sweating at night: Yes No Teeth grinding at night: Yes No Inability to move while falling asleep: Yes No Have Unusual vision at sleep onset: Yes No Feel Groggy/tired on awakening: Yes No Have Morning headaches on awakening: Yes No Wake up with dry mouth: Yes No Nightmares: Yes No Have Seizures during sleep: Yes No Have Daytime sleepiness: Yes No Have Daytime fatigue: Yes No Fights sleep while driving: Yes No Have Loss of strength/falls when startled: Yes No Have Memory problems: Yes No Had motor vehicle accident due to sleepiness: Yes No History of narrowed airway or enlargement of tonsils/adenoids: Yes No History of Tonsillectomy/Adenoidectomy: Yes No Prolong sitting at work or home or Lack of regular exercise: Yes No Sleep Study in past: Yes No CPAP or BiPaP tried in past: Yes No *I have reviewed and completed all 3 pages of History Form today. *Consent to Treatment: I hereby give my consent for medical treatment by the physicians or under the direction of the physicians of Neurology and Sleep Clinic.
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