New Patient Form - DuPage Sleep Solutions

Patient Information

First Name *

Middle Initial

Last Name *

Preferred Name

Date of Birth *

Biological Sex *

Male Female Intersex

Gender Identity

Male Female Non-binary Prefer to self-describe Prefer not to say

Marital Status

Single Married Partnered Separated Divorced Widowed

Height *

Weight (lbs) *

Neck (inches)Used for sleep apnea screening

Preferred Language

Contact Information

Street Address *

Apt / Unit

City *

State *

ZIP *

Cell Phone *

Home Phone

Email Address *

Preferred Contact Method *

Cell phone Home phone Email Text message

OK to Leave Voicemail?

Yes No

OK to Send Text Messages?

Yes No

Emergency Contact

Full Name *

Relationship *

Phone *

Insurance & Referral

Optional — you may also bring cards to your visit

Primary Insurance Carrier

Member / Policy ID

Group Number

Policyholder Name (if not self)

Relationship to Policyholder

Self Spouse Child Other

Primary Care Physician

Referring Physician

How Did You Hear About Us?

Reason for Visit

What is the main reason for today's visit? *

Main sleep concerns (select all that apply) *

Loud snoring Difficulty falling asleep Difficulty staying asleep Waking too early Excessive daytime sleepiness Stop breathing / gasping in sleep Restless or uncomfortable legs Teeth grinding Nightmares Sleepwalking or talking Other

If "Other" — please describe

How long have symptoms been present? *

Less than 1 month 1–6 months 6–12 months 1–5 years More than 5 years

Had a sleep study before? *

Yes No

If yes, when and where?

Currently using a sleep therapy device? *

No CPAP BiPAP APAP Oral appliance Other

Sleep Habits & Patterns

Bedtime — Weeknights *

Wake Time — Weeknights *

Bedtime — Weekends

Wake Time — Weekends

Minutes to fall asleep

Times waking per night

Avg hours of sleep *

Do you feel rested upon waking? *

Always Usually Sometimes Rarely Never

Naps per day

Caffeine drinks/day

Time of last caffeine

Work schedule

Regular daytime Night shift Rotating shift Irregular / on-call Not currently working

Use screens (phone / TV) in bed?

Yes No Sometimes

Sleep Symptoms Checklist

Check anything you experience

Symptoms

Snore loudly Others notice I stop breathing Wake up gasping or choking Wake with a dry mouth Wake with morning headaches Heartburn that wakes me Restless legs when sitting/lying Kick or jerk legs while asleep Grind or clench teeth Sleepwalk / talk / eat while asleep Nightmares or night terrors Wake up unable to move Racing thoughts at night Night sweats Frequent nighttime urination Have fallen asleep while driving Difficulty breathing through nose Unrefreshed even after full night

Daytime Sleepiness Scale (Epworth)

0 = Would never doze · 1 = Slight chance · 2 = Moderate chance · 3 = High chance of dozing

Sitting and reading *

0 1 2 3

Watching TV *

0 1 2 3

Sitting inactive in a public place (theater or meeting) *

0 1 2 3

As a passenger in a car for an hour without a break *

0 1 2 3

Lying down to rest in the afternoon when circumstances permit *

0 1 2 3

Sitting and talking to someone *

0 1 2 3

Sitting quietly after a lunch without alcohol *

0 1 2 3

In a car, while stopped for a few minutes in traffic *

0 1 2 3

Sleep Apnea Risk Screening (STOP-BANG)

Do you snore loudly (louder than talking, or loud enough to be heard through a closed door)? *

Yes No

Do you often feel tired or fatigued during the daytime? *

Yes No

Has anyone observed you stop breathing during your sleep? *

Yes No

Do you have, or are you being treated for, high blood pressure? *

Yes No

Is your Body Mass Index (BMI) more than 35? *

Yes No Not sure

Are you older than 50 years? *

Yes No

Is your neck circumference greater than 16 inches (40 cm)? *

Yes No Not sure

Is your biological sex male? *

Yes No

Medical History

Current or past medical conditions (select all that apply)

High blood pressure Heart disease Heart attack Irregular heartbeat / AFib Stroke or TIA Diabetes Thyroid disorder Asthma COPD GERD / acid reflux Depression Anxiety Chronic pain Kidney disease Migraines / headaches Nasal allergies / congestion Deviated septum Enlarged tonsils Obesity Fibromyalgia Seizure disorder None of the above

Other medical conditions

Current medications (name & dose)

No known drug allergies

Drug / food allergies

Prior surgeries (select all that apply)

Tonsillectomy / adenoidectomy Nasal or sinus surgery UPPP / throat surgery Bariatric (weight-loss) surgery Jaw / dental surgery None

Other surgical history

Social History

Tobacco use

Never Former Current

If current or former — amount and years

Alcohol use

None Occasional 1–7 drinks/week 8–14 drinks/week 15+ drinks/week

Recreational drug use

Yes No Prefer not to say

Exercise frequency

None 1–2×/wk 3–4×/wk 5+×/wk

Occupation

Family History

Family history of sleep disorders (select all that apply)

Sleep apnea Insomnia Narcolepsy Restless legs syndrome Loud snoring None known

Which family member(s)?

Consent & Acknowledgment

I confirm the information provided is accurate to the best of my knowledge. *

I consent to evaluation and treatment by the clinic. *

I acknowledge receipt of the HIPAA Notice of Privacy Practices. *

Patient / Guardian Signature (type full name) *

Date *

Leave this field empty