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Sleep Disorder Evaluation Date Start time Stop time Patient Name Chief complaint/Reason for consult Pt DOB Referring MD Allergies Allergy List reviewed No drug allergies No food allergies History of Present Illness Patient is Nonverbal. History obtained from Family Medical records Medications Medication list reviewed Medications reconciled with Nursing Home or Hospital discharge Information 46 Benzodiazepines Seizure medications Tricyclic antidepressants Neuroleptic medications Antihistamines, first generation Patient takes antidepressants, benzodiazepines, stimulants, narcotics, anti-seizure medications, alcohol or recreational drugs Loud snoring or gasping, choking sounds while sleeping Excessive daytime sleepiness Witnessed apnea followed by snorts and loud snoring Auto accidents in the past 12 months Frequent nocturnal awakenings Sleep walking or eating Difficulty falling asleep or staying asleep Night terrors Personality changes, increased irritability, depression Leg jerks while sleeping Paralysis at beginning of waking or sleeping Restless legs symptoms Sudden muscle weakness associated with strong emotions Weight gain or loss of >10 pounds in the past year Estimated number of hours of sleep/night # Caffeinated beverages consumed/day Social History Never Smoker Tobacco ____ # Packs X ____ # Yrs Quit Nicotine replacement Patient has tried Buproprion or nortriptyline Nicotine receptor blockade Daily, occasional and ex-smokers are more likely to be hazardous drinkers Review of Systems WNL Alcohol use ______ Drinks per day Hazardous drinking week NIAAA (National Institute on Alcoholism and Alcohol Abuse guidelines) Men > 14 drinks per week OR > 4 drinks per day Women > 7 drinks per week OR >3 drinks per day Recreational drug use Inhalational Injectable Ingestible Constitutional Fatigue malaise fever/chills change in appetite Eyes Vision changes New pain Scotomas ENT/mouth Nose bleeds dental caries dental abscesses jaw pain Resp Dyspnea Cough Phlegm Hemoptysis Wheeze CV Chest pain diaphoresis Ankle edema PND syncope GI Nausea Weight changes Constipation Diarrhea Abdominal pain GU Change in urinary habits Hematuria Dysuria Musc Myalgias Recent trauma Bony fractures Arthralgias Joint swelling Skin/breasts Rashes Masses or skin lesions Increased sensitivity to sun Neuro Seizures Episodic or chronic muscle weakness Headaches Endo Hair loss Polydipsia Tremors Neck pain Heme/lymph Bleeding gums Unusual bruising swollen lymph nodes Allergy/Immun Sinus probs Recurrent infections Psych Mood changes Agitation Psychosis Delirium Dementia Occupational History Shift work If yes, describe work schedule Drug dependence Narcotics Benzodiazepines Family Medical History Asthma Congestive Heart Failure COPD Coronary Artery Disease Premature Onset Narcolepsy Neuromuscular Disease Obstructive Sleep Apnea Pancreatitis Peripheral Artery Disease Renal Dysfunction Thrombotic disorder Thyroid Disease Malignancy Past Medical History Asthma Cerebral Artery Disease Congestive Heart Failure COPD Coronary Artery Disease GERD Hepatic Dysfunction Hypertension Malignancy, specify Neuromuscular weakness PAH Peripheral Artery Disease Rheumatoid arthritis Sarcoidosis Scleroderma Seizure Disorder Thyroid Disease Surgical History Deviated septum Denies surgical history Head and neck cancer ENT surgeries Insomnia Rhinoplasty Narcolepsy Jaw surgery Obstructive Sleep Apnea Polypectomy Radiation to neck or head Uvulopalatopharyngoplasty Restless Legs Syndrome Periodic Leg Movement Disorder Swallowing disorder Vaccines Flu Pneumo BCG Tetanus Pertussis Varicella ©MB and RR 2006-2008 Revised 3Mar08 Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures Sleep Disorder Evaluation Prior Diagnostic Data ECHO/Stress Test Sleep Study Full night Split night Apnea/Hypopnea Index ___ Multiple Sleep Latency Test Maintenance Wakefulness Test Patient Name Exam General ENT Neck Resp Alert Vitals Nasal mucosa Pt DOB T Dentition P Thyroid R Oropharynx No JVD BP Mallampati I II Sats III IV % Normal to palpation Clear to auscultation No chest wall defects Dullness to percussion Decreased fremitus No respiratory distress Bronchial breath sounds Egophony (E to A change) Peripheral pulses No peripheral edema Absence of intercostal respiratory retractions CV GI Musc Clear S1 S2 No murmur No gallop No rub No palpable masses Liver and spleen not palpable No hepatojugular reflux Lymph Extrem Skin Neuro Plan Pneumonia vaccine Influenza vaccine Smoking cessation aids Labs No lymphadenopathy Tone Gait No cyanosis No clubbing No rashes, ecchymoses, nodules, ulcers Oriented 58(Pts with Community Acquired Bacterial Pneumonia) Affect Impression Epworth Sleepiness Score 12-lead EKG Echocardiogram CXR Inspiratory and Expiratory CT of Chest Pulmonary Function Testing Overnight Polysomnography MSLT Maintenance Wakefulness Test CPAP BiPAP Supplemental Oxygen Follow Up Signature cc: Patient has completed advanced health care directives 47 HCPOA is Code Status Patient is a FULL CODE DO NOT ATTEMPT RESUSCITATION ©MB and RR 2006-2008 Revised 3Mar08 Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures

Template updated on 2/11/08