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USA Sleep Diagnostic Mobile Service

Blank Patient Intake Packet

Type your answers below, then print or save as PDF — or print it blank and fill it in by hand.

Patient Information

First name
Middle name
Last name
Date of birth
Email address
Sex:Marital status:
Street address
City
State
ZIP code
Cell phone
Work phone

Contacts and Providers

Primary care physician

PCP name
PCP phone
PCP fax

Emergency contact

Full name
Relationship
Home phone
Work phone
Address

Insurance Information

Primary insurance

Type:
TRICARE plan:
Insurance name
Member ID (TRICARE: 11-digit DoD ID)
Group #
Insurance phone
Insurance address

Secondary insurance (optional)

Insurance name
Member ID
Group #
Insurance phone
Insurance address

I authorize USA Sleep Diagnostic Mobile Services, LLC, to contact my insurance company to verify my insurance coverage. I understand that if I am not eligible, I am liable for all charges rendered. I authorize USA Sleep Diagnostic Mobile Service to release any medical information necessary to process my insurance claim and to receive payment of medical benefits directly.

Signature
Date

Sleep Questionnaire

Age
Height (ft)
Height (in)
Weight (lbs)
Neck (in)

Sleep problems — check all that apply

How long have you had these problems?

Medical conditions — check all you have

If yes to any, please describe
Other medical problems
Current medications (and dose if known)
Previous surgeries

Sleep environment

Do you read in bed?
Do you watch TV in bed?
Do you share the bed with anyone?
Does your partner have a sleep disorder?
Do you have pets in the bedroom?
What is the temperature in your room?

Social history

Have you ever smoked?
Have you quit smoking?
Do you drink alcohol?
Do you drink caffeinated beverages?
Avg packs/day
Quit how long ago?
Drinks/day
Caffeine/day

Daytime function (0 = not at all, 2 = sometimes, 4 = all the time)

Are you sleepy during the day?
Do you have trouble concentrating?
Do you fall asleep unintentionally?

Sleep schedule

Weekday bedtime
Weekday wake time
Weekend bedtime
Weekend wake time
Weekday sleep hrs
Weekend sleep hrs
Hours needed to feel rested
Medication allergies
Current occupation
Work hours

STOP-BANG Questionnaire

Snoring — Do you snore loudly (loud enough to be heard through closed doors)?
Tired — Do you often feel tired, fatigued, or sleepy during the daytime?
Observed — Has anyone observed you stop breathing during your sleep?
Pressure — Do you have or are you being treated for high blood pressure?
BMI — Is your body mass index greater than 35 kg/m²?
Age — Are you over 50 years old?
Neck — Is your neck circumference greater than 16 inches (40 cm)?
Gender — Are you male?

Epworth Sleepiness Scale

How likely are you to doze off or fall asleep? 0 = would never doze, 1 = slight chance, 2 = moderate chance, 3 = high chance.

Sitting and reading
Watching TV
Sitting inactive in a public place (e.g., a theater or meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic
Total score

Review of Systems

Check any symptoms you currently have.

General
Skin
HEENT
Cardiovascular
Pulmonary
Gastrointestinal
Genitourinary
Musculoskeletal
Neurological
Psychiatric
Additional notes (optional)

Authorization for Release of Medical Records

I authorize USA Sleep Diagnostic Mobile Service to release my medical records — including sleep study reports, physician notes, prescriptions, and related information — to my primary care provider (listed in the Contacts and Providers section of this packet) for the purpose of coordinating my care.

This authorization remains in effect for the duration of my care with USA Sleep Diagnostic Mobile Service unless I revoke it in writing.

Patient signature
Date

Acknowledgments and Signature

Please read and initial each acknowledgment.

Insurance authorization
I authorize USA Sleep Diagnostic Mobile Service to contact my insurance to verify coverage, release information needed to process claims, and receive payment of benefits directly. I am liable for charges not covered by insurance.Initials
Cancellation policy
USA Sleep Diagnostic Mobile Service reserves appointment time specifically for me. I'll give at least 24 hours notice to cancel or reschedule. Late cancellations or no-shows may be subject to a fee.Initials
Consent for treatment
I voluntarily consent to medical care, evaluation, and diagnostic services provided by USA Sleep Diagnostic Mobile Service and its personnel.Initials
Communications
I authorize USA Sleep Diagnostic Mobile Service to contact me about appointments, test results, and care by phone, text message, email, or mail.Initials
Financial responsibility
I accept financial responsibility for services rendered, including any balance not covered by insurance.Initials
HIPAA authorization
I authorize USA Sleep Diagnostic Mobile Service to use and disclose my protected health information for treatment, payment, and health care operations, as described in the Notice of Privacy Practices. I may revoke this authorization in writing at any time, except to the extent action has already been taken in reliance on it.Initials
Release of medical records
I authorize USA Sleep Diagnostic Mobile Service to release or obtain records to/from the providers I listed in this packet (if any).Initials
Telemedicine consent
I consent to receive sleep diagnostic services, including consultation, by telemedicine. I understand the same confidentiality protections that apply to in-person care apply to telemedicine, and I may withdraw consent at any time without affecting my right to future care.Initials
Patient rights & responsibilities
I acknowledge I've been provided with USA Sleep Diagnostic Mobile Service's Patient Rights & Responsibilities, including the right to respectful care without discrimination, to information about charges and services, to participate in care decisions, and to confidentiality of my health information.Initials
Notice of Privacy Practices
I acknowledge I've received USA Sleep Diagnostic Mobile Service's Notice of Privacy Practices, which describes how my medical information may be used, disclosed, and accessed.Initials

Text Message (SMS) Consent — Optional

Checking this box is optional. It is not required to complete this paperwork, schedule an appointment, make a purchase, or receive healthcare services. You may leave it unchecked and still receive services.

My signature below confirms the required acknowledgments I initialed above. SMS consent is separate and applies only if I affirmatively check the optional box.

Patient or legal representative signature
Date
Printed name
Relationship, if applicable