PATIENT INFORMATION
PHYSICIAN INFORMATION
Please describe reason for visit:
MEDICAL HISTORY
Have you been Diagnosed with Depression, Anxiety or Bipolar Disorder? Depression Anxiety Bipolar Disorder None of the above
Any other health diagnoses?
Prior Surgeries with dates:
Prior Hospitalizations with Dates & Location:
Medication List with Dose (mg), Frequency and Date Started:
FAMILY HISTORY
SOCIAL HISTORY
Check any of the following problems that apply to you?
Fever or chills; Sweats excessively; Sinus problems; Nasal congestion; Vision problems; Hearing problems; Heartburn; Swallowing problems; Nighttime cough; Daytime cough; Wheezing; Breathing/lung problems; Chest pains; Diarrhea or constipation; Nausea or vomiting; Depression; Panic Attacks; Joint pain or swelling; Headaches; Fainting spells; Fatigue or loss of energy; Weight loss Hormonal problems (thyroid or other); Blood diseases; Low iron levels; Speech difficulties; Muscle pain; Developmental problems; Anxiety/stress; Liver problems; Problems urinating; Fallen in the last year;
SLEEP HISTORY
Do you or have you been told you (any of the following)?Sleep talk; Sleep walk; Teeth grind; Having pain in the legs; Have twitching legs awake or asleep; Fall asleep at work; Use sleep aids; Have hallucinations upon falling asleep/awakening; Have inability to move your body (paralysis) upon falling asleep/awakening; Have difficulty falling asleep (more than 20-30 minutes in bed); Ever have sleep attacks, suddenly fall asleep; Become weak, especially when angry or laughing; Fall asleep in odd situations/places; Complain of being sleeping/tired; Gasp, snort, wake yourself up with your breathing; Have vivid dreams or acting them out; Doze off, near misses or accidents when driving; Any recent weight change in past 12 months; Have morning headaches; Experience GERD/Reflux/Indigestion at night;
EPWORTH SLEEPINESS SCALE
How likely are you to doze off or fall asleep in the situations described below, in contrast to feeling just tired?
0 = Would Never Doze
Sitting and Reading: 0 - Never 1 - Slight Chance 2 - Moderate Chance 3 - High Chance
Watching TV: 0 - Never 1 - Slight Chance 2 - Moderate Chance 3 - High Chance
Sitting, inactive in a public place (theatre or meeting): 0 - Never 1 - Slight Chance 2 - Moderate Chance 3 - High Chance
As a passenger in a care for an hour without a break: 0 - Never 1 - Slight Chance 2 - Moderate Chance 3 - High Chance
Lying down to rest in the afternoon when circumstances permit: 0 - Never 1 - Slight Chance 2 - Moderate Chance 3 - High Chance
Sitting and talking to someone: 0 - Never 1 - Slight Chance 2 - Moderate Chance 3 - High Chance
In a car, while stopped for a few minutes in traffic: 0 - Never 1 - Slight Chance 2 - Moderate Chance 3 - High Chance
Sitting quietly after lunch: 0 - Never 1 - Slight Chance 2 - Moderate Chance 3 - High Chance
*All questions above need to be answered for the form to be successfully submitted.
