Narcolepsy Sleep Study Intake
Patient Information
Full Name
Date of Birth
Gender
Male
Female
Other
Prefer not to say
Phone
Email
Referring Provider
Provider Name
Practice / Facility
Sleep History
Primary Sleep Concerns
Onset & duration of symptoms
Previous Sleep Study?
Yes
No
If yes, when/where and results
Epworth Sleepiness Scale
Score
Cateplexy (sudden muscle weakness episodes)
Describe frequency/triggers
Medications
Current medications (include sleep aids, stimulants, antidepressants, etc.)
Relevant Medical History
Other medical/psychiatric conditions
Family history of narcolepsy or sleep disorders
Additional Notes