Sleep Study Intake Form
for Cardiovascular Patients
Patient Information
Full Name
Date of Birth
Age
Gender
Male
Female
Other
Email
Phone Number
Address
Referring Cardiologist
Name
Contact Info
Medical History
Cardiovascular Conditions
Other Medical Conditions
Current Medications
Allergies
Sleep History
Main Sleep Concerns
Duration of Sleep Problems (months/years)
Do you snore?
Yes
No
Unsure
Daytime Sleepiness
Never
Sometimes
Often
Always
Previous Diagnosis of Sleep Apnea?
Yes
No
Lifestyle & Habits
Smoking Status
Never
Former
Current
Alcohol Use
Never
Occasionally
Frequently
Exercise Habits
Additional Comments