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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Sleep Disorder Evaluation Template
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,… (More)
Sleep disorders include obstructive sleep apnea, narcolepsy,… (More)
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