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Sleep Disorder Evaluation Template

Sleep Disorder Evaluation Template

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Published by e-MedTools
The Sleep Disorder evaluation MedicalTemplate is suitable for any physician or health care provider that evaluates patients with sleep disorders such as sleep apnea, narcolepsy, or restless leg syndrome.

Sleep disorders include obstructive sleep apnea, narcolepsy, restless leg syndrome, insomnia, night terrors and others. The National Center on Sleep Disorders Research (NCSDR) estimates that 42 million Americans suffer from a chronic sleep disorder. Sleep disorders are associated with chronic sleep deprivation, elevated blood pressure, cardiovascular disease, pulmonary hypertension, cognitive dysfunction, erectile dysfunction, chronic fatigue, and other medical conditions that result in $15.9 billion in health care costs annually. Sleep disorders can have a detrimental influence in the workplace and school performance, and people who are chronically sleep deprived due to sleep disorders are at increased risk of auto accidents.

The Sleep Disorder Evaluation MedicalTemplate has prompters for the sleep history, medical history, medication use that affects sleep architecture, drug use history, auto accident history, physical examination, and testing options. This assists physicians in efficiently documenting a thorough history.
The Sleep Disorder evaluation MedicalTemplate is suitable for any physician or health care provider that evaluates patients with sleep disorders such as sleep apnea, narcolepsy, or restless leg syndrome.

Sleep disorders include obstructive sleep apnea, narcolepsy, restless leg syndrome, insomnia, night terrors and others. The National Center on Sleep Disorders Research (NCSDR) estimates that 42 million Americans suffer from a chronic sleep disorder. Sleep disorders are associated with chronic sleep deprivation, elevated blood pressure, cardiovascular disease, pulmonary hypertension, cognitive dysfunction, erectile dysfunction, chronic fatigue, and other medical conditions that result in $15.9 billion in health care costs annually. Sleep disorders can have a detrimental influence in the workplace and school performance, and people who are chronically sleep deprived due to sleep disorders are at increased risk of auto accidents.

The Sleep Disorder Evaluation MedicalTemplate has prompters for the sleep history, medical history, medication use that affects sleep architecture, drug use history, auto accident history, physical examination, and testing options. This assists physicians in efficiently documenting a thorough history.

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Published by: e-MedTools on Sep 12, 2008
Copyright:Traditional Copyright: All rights reserved

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08/21/2015

 
Sleep Disorder Evaluation
Patient Name
 
Pt DOB
©MB and RR 2006-2008 Revised 6Feb08
Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures
DateChief complaint/Reason for consult Referring MD
Start timeStop time
MedicationsHistory of Present Illness
Patient is Nonverbal. History obtained from
Family
Medical records
Medication list reviewed
Medications reconciled with Nursing Home or Hospital dischargeInformation
46Changes as followsAllergies
 Allergy List reviewed
No drug allergies
No food allergies 
Patient takes antidepressants, benzodiazepines, stimulants, narcotics, anti-seizure medications, alcohol or recreational drugs
Loud snoring or gasping, choking sounds
Excessive daytime sleepiness
Witnessed apnea
 Auto accidents in the past 12 months
Fatigue despite adequate sleep
Sleep walking or eating
Vivid dreams
Night terrors
Difficulty falling asleep or staying asleep
Leg jerks while sleeping
Hypnogogic or Hynopompic symptoms
Restless legs symptoms
Sudden muscle weakness associated with strong emotions
Recent weight gain of >10 pounds
Estimated number of hours of sleep/night
# Caffeinated beverages consumed/day
Social HistoryReview of Systems
Never Smoker 
Tobacco ____ # Packs X ____ # Yrs
QuitPatient has tried
Nicotine replacement
Buproprion or nortriptyline
Nicotine receptor blockade
Daily, occasional and ex-smokers are morelikely to be hazardous drinkers
 Alcohol use ______ Drinks per 
day
week
Hazardous drinking 
NIAAA (National Institute on Alcoholismand 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
Drug dependence
Narcotics
Benzodiazepines
See HPI WNL

Constitutional
Fatigue, malaise, fever/chills, weight loss, 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, Witnessed Apnea

CV
Chest pain, diaphoresis, ankle edema, PND, syncope

GI
Emesis, dysphagia, GERD, abdominal pain, diarrhea, melena

GU
Change in urinary habits, hematuria, dysuria

Musc
Myalgias, recent trauma, bony fractures, arthralgias, joint swelling

Skin/breasts
Rashes, new masses or skin lesions, increased sensitivity to sun

Neuro
Seizures, episodic or chronic muscle weakness

Endo
Hair loss, polydipsia

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
Family Medical History Past Medical History Surgical History
Asthma
Congestive Heart Failure
COPD
Coronary Artery Disease
Premature Onset
Malignancy
Narcolepsy
Neuromuscular Disease
Obstructive Sleep Apnea
Pancreatitis
Peripheral Artery Disease
Renal Dysfunction
Thrombotic disorder 
Thyroid Disease
Asthma
Deviated septum
Denies surgical history
Cerebral Artery Disease
Head and neck cancer 
ENT surgeries
Congestive Heart Failure
Insomnia
Rhinoplasty
COPD
Narcolepsy
Jaw surgery
Coronary Artery Disease
Nasal polyps
Polypectomy
GERD
Obstructive Sleep Apnea
Uvulopalatopharyngoplasty
Hepatic Dysfunction
Radiation to neck or head
Hypertension

Restless Legs Syndrome
Neuromuscular weakness
Periodic Leg Movement Disorder 
PAH
Swallowing disorder 
Peripheral Artery Disease
Rheumatoid arthritis
Sarcoidosis
Scleroderma

Seizure Disorder 

Thyroid Disease
Vaccines
Flu
Pneumo
BCG
Tetanus
Pertussis
Varicella

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