Please print clearly and complete every section that applies to you.
Patient Information
First name
Middle name
Last name
Date of birth
Sex
Marital status
Street address
City
State
ZIP code
Cell phone
Work phone
Email address
Contacts and Providers
Primary care provider
Provider phone
Provider fax
Emergency contact
Relationship
Emergency contact phone
Alternate phone
Emergency contact address
Insurance Information
Primary insurance
Member / policy number
Group number
Insurance phone
Claims address
□ TRICARE□ HMO□ PPO□ Other
DoD Benefits Number (TRICARE patients)
Secondary insurance
Member / policy number
Sleep and Medical History
Height
Weight
Neck size
Main sleep concerns and how long you have had them
Medical conditions
Current medications and doses
Medication allergies
Previous surgeries
Usual weekday bedtime / wake time
Weekend bedtime / wake time
Hours of sleep each night
Hours needed to feel rested
Snore loudly□ Yes □ No
Feel tired during the day□ Yes □ No
Observed stopping breathing□ Yes □ No
High blood pressure□ Yes □ No
Fall asleep unintentionally□ Yes □ No
Trouble concentrating□ Yes □ No
Smoke or use tobacco□ Yes □ No
Drink alcohol□ Yes □ No
Use caffeine□ Yes □ No
Other medical or sleep information
Epworth Sleepiness Scale
Rate your chance of dozing: 0 = never, 1 = slight, 2 = moderate, 3 = high.
Sitting and reading0 1 2 3
Watching television0 1 2 3
Sitting inactive in a public place0 1 2 3
Passenger in a car for one hour0 1 2 3
Lying down to rest in the afternoon0 1 2 3
Sitting and talking to someone0 1 2 3
Sitting quietly after lunch0 1 2 3
Stopped in traffic while driving0 1 2 3
Total score
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 this packet for care coordination. This authorization remains in effect during my care unless I revoke it in writing.
Patient signature
Date
Acknowledgments and Signature
Initial each applicable acknowledgment after reviewing the complete policies provided by USA Sleep Diagnostic Mobile Service.
Initials ______Insurance authorization
Initials ______Cancellation policy
Initials ______Consent for treatment
Initials ______Communications
Initials ______Financial responsibility
Initials ______HIPAA authorization
Initials ______Release of medical records
Initials ______Telemedicine consent
Initials ______Patient rights and responsibilities
Initials ______Notice of Privacy Practices
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.