Pre-Sleep Study Medical History Form
Patient Information
Full Name
Date of Birth
Gender
Male
Female
Other
Phone Number
Address
Referring Physician
Physician Name
Clinic / Hospital
Medical History
Check any conditions you have:
Hypertension
Diabetes
Heart Disease
Asthma
Other Medical Conditions
Sleep History
Primary Sleep Complaint
Duration of Sleep Problem
Do you snore?
Yes
No
Don't Know
How many times do you wake up during the night?
Current Medications
List all current prescription and non-prescription medications:
Allergies
List allergies (medications, foods, etc):
Family History
Sleep disorders or related conditions in the family:
Social History
Do you smoke?
Never
Current Smoker
Former Smoker
Do you use alcohol?
No
Yes
Daily caffeine intake