Sleep Study Form Name * First Name Last Name Date of Birth * MM/DD/YYYY Sex * Male Female Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Primary Insurance Company * Epworth Sleepiness Scale In contrast to just feeling tired, how likely are you to doze off or fall asleep in the following situations? This refers to your usual life. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation. If none of these apply to you or your situation, please just fill in the number (0) in the blank. Use the following scale to choose the most appropriate number for each situation. 0 = Would never doze off/fall asleep 1 = Slight chance of dozing off/falling asleep 2 = Moderate chance of dozing off/falling asleep 3 = High chance of dozing off/falling asleep Sitting & Reading * 0 1 2 3 Watching TV * 0 1 2 3 Lying down to rest in the afternoon * 0 1 2 3 Sitting inactive in a public place (i.e. theatre/meeting) * 0 1 2 3 As a passenger in a car for an hour, with no break * 0 1 2 3 Sitting quietly after lunch * 0 1 2 3 In a car stopped for a few minutes * 0 1 2 3 Have you ever been diagnosed with a sleep disorder? * Yes No Night time oxygen use? * Yes No Are you currently using a CPAP machine? * Yes No Have you ever been told you stop breathing while asleep? * Yes No Have you ever fallen asleep or nodded off while driving? * Yes No Have you ever woken up suddenly with shortness of breath, gasping or with your heart racing? * Yes No Do you feel excessively sleepy during the day? * Yes No Do you snore or have you ever been told that you snore? * Yes No Have you had weight gain and found it difficult to lose? * Yes No Have you taken medication for, or been diagnosed with high blood pressure? * Yes No Do you kick or jerk your legs while sleeping? * Yes No Do you feel burning, tingling, or crawling sensations in your legs when you wake up? * Yes No Do you wake up with headaches during the night or in the morning? * Yes No Do you have trouble falling asleep? * Yes No Do you have trouble staying asleep once you fall asleep? * Yes No Consent to Treat * I hereby authorize employees and agents of this medical office to render medical care to the patient indicated on this form and to fulfill the orders of the provider’s choice. The duration of this consent is indefinite and continues until revoked in writing. I understand that by not signing this consent, the patient WILL NOT be provided medical care except in a case of emergency. I consent Financial Responsibility * I hereby authorize payment of medical benefits directly to Neurology Care for services rendered. Authorization is hereby granted to release all information contained in my medical record to my medical insurance company (or its employees or agents) as may be necessary to process and complete my medical insurance claim. I understand that this authorization may include release of information regarding communicable diseases, such as “AIDS” and “HIV”. I understand that I am financially responsible for the total charges for services rendered which may include services not covered by my insurance companies. I agree that all amounts are due upon request and are payable to Neurology Care. I further understand should my account become delinquent; I shall pay any expense incurred by Neurology Care in the collection of that account, if any. You agree, in order for us to service your account or to collect any amounts you may owe, we or a collection agency (as necessary) may contact you be telephone at any number associated with your account, including wireless numbers, which could result in charges to you. We may also contact you by sending text messages or e-mails, using any e-mail address you provide to use. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable. The duration of this authorization is indefinite and continues until revoked in writing. I understand that by not signing this release of information, I am responsible for payment of services in full before the services are rendered. I consent Privacy Notice Acknowledgement for the Office of Neurology Care * This office takes the confidentiality of your medical information very seriously. We are providing privacy notices which make you aware of what the office can and cannot do with you protected health information (PHI). Please acknowledge receipt of the privacy notice by signing and dating this letter in the space provided below. If you have any questions regarding this matter, please contact the chief privacy officer: Officer: Yousef Abu-Esheh Phone: 580-223-0447 Address: 908 N. Rockford Rd, Ste A, Ardmore, OK 73401 I consent Clinic Rules * All co-pays/estimated co-insurances are due at the time of the visit. Note: All co-insurances are estimates of what you will owe from what is paid by your insurance, the price that is quoted to you is not definite as we are not responsible for what your insurance pays. We have daily booked appointments scheduled out in advance so, if you are 15 or more minutes late to your appointment, it may have to be rescheduled. We request 24-hour notification for appointment cancellations. Any patient who has been turned to collections will not be able to make an appointment until the balance is resolved. All children are welcome in this clinic; however, if they become disruptive, we will ask you to reschedule your appointment for another day. I consent Name * First Name Last Name Date * MM/DD/YYYY Thank you!
