New Patient Sleep Questionnaire and Forms

PULMONARY CARE SPECIALISTS, PA
4333 N. Josey Ln., Plaza 2, Suite 207, Carrollton 75010
972-394-2971 Fax 972-492-1261
James P. Loftin, M.D.
Melissa L. Tompkins, M.D.
Dear New Patient;
It is very important that you complete the following questionnaire for the appointment you have scheduled on
_________________________________. By answering all of the questions as completely as possible before
your appointment, you will save considerable time in the doctor’s office. If you do not complete this paperwork
prior to your appointment, please arrive an hour early to do so.
When you arrive for your appointment, please present a current insurance card to the receptionist. If your
insurance plan requires a referral from your primary care provider, please bring it with you. If no referral is
presented, the receptionist will have to re-schedule your appointment. If you do not know if your insurance
plan requires a referral, call the benefits phone number on your insurance card and ask.
Please call twenty-four hours in advance if you are unable to keep your appointment. Since there are a
limited number of new patient appointment times per week, many patients wait one or two months for an
appointment. When a new patient does not show up for an appointment or reschedules less than 24 hours in
advance, there is not enough time to call a patient who has been waiting for an appointment. Therefore, due to
the high increase in the number of patients not showing up for their scheduled appointment, if you do not
show up for your appointment or reschedule less than 24 hours before your appointment, we will not be able to
reschedule your appointment for a later date. There will also be a fee of $35.00 billed directly to you and
not to your insurance company.
If you have any questions, please call the office where you are scheduled. We look forward to your first visit
with our caring staff.
Sincerely,
James P. Loftin, MD
Melissa L. Tompkins, MD
Kathy Deans, PA-C
PATIENT SLEEP HISTORY QUESTIONNAIRE
Patient Name: ____________________________________________ Date: __________________________
Referring Physician & Phone #: _______________________________________________________________
Age: _________________________ Height: _____________________ Weight: ________________________
Have you had a recent weight gain or loss?
No _________ Yes _______
If YES, Please explain (ex: how much in what length of time): ___________________________
MEDICAL HISTORY
Do you now have or have you ever had:
High Blood pressure
Allergies
COPD
Stroke
Nasal Fracture
Diabetes
Nocturnal Esophageal Reflux
Swelling of hands or feet
Laser Surgery for snoring
______ No ______ Yes
______ No ______ Yes
______ No ______ Yes
______ No ______ Yes
______ No ______ Yes
______ No ______ Yes
______ No ______ Yes
______ No ______ Yes
______ No ______ Yes
Sinus Problems
Heart Problems
Asthma
Tonsillectomy
Nasal Surgery
Multiple Sclerosis
______ No ______ Yes
______ No ______ Yes
______ No ______ Yes
______ No ______ Yes
______ No ______ Yes
______ No ______ Yes
Other Medical Problems: _____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
LIST MEDICATIONS:
TIME OF LAST DOSE
REASON FOR MEDICATION
_____________________________
_____________________________
________________________________
_____________________________
_____________________________
________________________________
_____________________________
_____________________________
________________________________
_____________________________
_____________________________
________________________________
_____________________________
_____________________________
________________________________
_____________________________
_____________________________
________________________________
LIST ALL SURGERIES:
YEAR
LIST ALL SURGERIES:
YEAR
_____________________________
__________
_______________________
_________
_____________________________
__________
_______________________
__________
MEDICAL ALLERGIES: ____________________________________________________________________________
SLEEP HISTORY
Describe in detail what your sleep problem is and how long this has been a problem: ________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Normal Bedtime:
Weeknights _______________
Weekends _________________
Normal Wake up Time
Weeknights _______________
Weekends _________________
When you awake in the morning do you feel refreshed?
Yes ____________ No __________
How long does it usually take you to fall asleep once the lights are turned off? _____________________________________________
Do you awaken during the night?
Yes ____________ No __________
How long does it take for you to return to sleep upon these awakenings? _________________________________________________
Do you take naps during the day?
Yes ____________ No __________
If YES, How often? _____________________________________________ Average Length: ________________________________
Do you feel refreshed upon awakening from these naps?
Yes ____________ No __________
Note the positions you normally sleep in:
Back _____
Right Side ______ Left Side _______ Stomach ______
Are you now, or have you ever been, under the care of a cardiologist? Yes ____________ No __________
Do you suffer from a racing heart or an irregular heartbeat?
Yes ____________ No __________
Do you suffer from dizziness, light-headedness, or fainting spell?
Yes ____________ No __________
Do you ever experience chest pains?
Yes ____________ No __________
Have you ever had a heart attack or mild cardiac infarction?
Yes ____________ No __________
Have you ever been diagnosed with a disorder of the central nervous system
Yes ____________ No __________
Please circle one of the following:
0= Not at all
1= Mild/very rarely/soft
2= Moderate/Occasionally
1. Do you snore?
2. Do you snore while lying on your back?
3. Do you snore while lying on your side?
4. Rate your snoring.
5. Do you hold your breath or stop breathing in your sleep?
6. Do you have difficulty breathing while lying on your back?
7. Do you have difficulty breathing while lying on your side?
8. Do you awaken suddenly with a choking sensation or out of breath?
9. Do you have gas, indigestion or heartburn at night?
10. Do you have night sweats?
11. Do you awaken with headaches in the morning?
12. Do you awaken with a dry mouth?
13. Do you have trouble breathing through your nose?
14. Do you experience shortness of breath with exertion?
15. Do you awaken at night to urinate?
16. When you awaken from sleep, do you ever feel paralyzed or
unable to move even though you are awake?
17. When someone startles you or makes you laugh, do you
get weak, fall or do your knees buckle?
18. While in the process of falling asleep, do you have vivid
dreams or hallucinations?
19. Do you have frequent uncontrollable bouts of sleep,
sleep attacks or an irresistible urge to sleep:
3= High/Frequently/Loud
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
20. Do your legs kick or twitch frequently during the night?
21. Do you have restless legs?
22. Do you have problems with memory or concentration?
0
0
0
1
1
1
2
2
2
3
3
3
23. Problems with impotence or lack of sexual interest?
24. Are you irritable?
25. Do you feel depressed?
0
0
0
1
1
1
2
2
2
3
3
3
26. Do you feel anxious?
27. Do you grind your teeth at night?
28. Do you feel sleepy during the day?
29. Do you feel fatigued during the day?
30. Do you have to fight sleep while driving?
31. Have you ever had a car wreck caused by sleepiness?
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
Please rate the chance of you dozing in the following situations:
0= never doze
1= slight chance of dozing
2= moderate chance of dozing
3= high chance of dozing
Sitting and reading
______________________________
Watching T.V.
______________________________
Sitting inactive in a public place, i.e. theater or meeting
______________________________
As a passenger in a car for a rest in the afternoon
______________________________
Lying down for a rest in the afternoon
______________________________
Sitting and talking to someone
______________________________
In a car while stopped for a few minutes in traffic
______________________________
Sitting quietly after lunch without alcohol
______________________________
Add the numbers for a total
TOTAL
______________________________
SLEEP ENVIROMENT
Do you sleep in a waterbed?
Yes ________
No ________
Do you read in bed?
Yes ________
No ________
Do you watch T.V. in bed?
Yes ________
No ________
Do you share the bed with anyone?
Yes ________
No ________
Does your partner have a sleep disorder?
Yes ________
No ________
Do you have pets in the bedroom?
Yes ________
No ________
What is the temperature in your bedroom?
_____________________________
SOCIAL HISTORY
Marital Status:
______ Single ______ Married ______ Divorced
______ Separated
______ Other
What is your present occupation?
___________________________________________________________
What are your work hours?
___________________________________________________________
Have you ever smoked?
If YES, for how many years?
Average number of packs per day
Have you quit smoking
How long ago?
Yes ________
No ________
___________________________________________________________
___________________________________________________________
Yes ________
No ________
___________________________________________________________
Do you drink caffeinated beverages?
Yes ________
No ________
If YES, how much per day?
___________________________________________________________
Do you drink alcoholic beverages?
If YES, how often?
Yes ________
No ________
___________________________________________________________
Do you get regular exercise?
If YES, how often?
Yes ________
No ________
___________________________________________________________
Do you have any unusual eating habits?
Yes ________
No ________
If YES, explain
___________________________________________________________
FAMILY HISTORY
Children:
Number ________ Ages ________________ Health _____________________________
Mother:
Living ________ Yes________ No Age ________ Health ______________________
Father:
Living ________ Yes________ No Age ________ Health ______________________
Brothers:
Ages: _______________________ Health _____________________________________
Sisters:
Ages: _______________________ Health _____________________________________
Does any member of your family have sleep problems? If so, please describe:
__________________________________________________________________________________________
__________________________________________________________________________________________
Now that you have answered your questionnaire, do you have any other comments that you would like to add?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
PULMONARY CARE SPECIALISTS
CONFIDENTIAL PATIENT DATA
Patient Name _______________________________ Birth Date ________________
Sex: M F
Address _______________________________
SS# ___________________________________
City, State, Zip __________________________
Occupation ____________________________
Preferred Pharmacy: Street, City, Zip Code ________________________________________________
Please check the preferred method of contact:
Home (____)______________________
Work (____)______________________
Cell
(____)______________________
Meaningful Use:
Race_____________________________
Language_________________________
Marital Status_____________________
______I give my consent to leave a detailed message with medical information
______I DO NOT give my consent to leave a detailed message with medical information
Email address: _________________________________________________________________________
Employer Name_________________________________________Phone__________________________
Employer’s Address_____________________________________________________________________
Primary Care Doctor____________________________________ Phone__________________________
Referring Doctor (If different) __________________________ Phone__________________________
Emergency Contact
Name______________________________
Relationship_________________________
Phone______________________________
Other______________________________
Responsible Party (if other than the
patient)
Name________________________________
Address______________________________
City, State, Zip_________________________
Phone________________________________
Relationship to patient___________________
Signature_____________________________________________________________
Printed Name__________________________________________________________
PULMONARY CARE SPECIALISTS
PRIMARY INSURANCE COVERAGE
Name of Insurance Company___________________________________ HMO_______PPO________
Subscriber/Card Holder Information: Name_____________________________ Birth Date___________
Policy #________________________________________________Group#_____________________________
Insurance Company Address______________________________________Phone number________________
SS#_______________________Relationship to Card Holder:
Self
Spouse
Child
Other
SECONDARY INSURANCE INFORMATION
Please circle one: I have secondary insurance
I do not have secondary insurance coverage
Name of Insurance Company_____________________________-_____________HMO_______PPO________
Subscriber/Card Holder Information: Name_________________________________Birth Date____________
Policy #________________________________________________Group#_____________________________
Insurance Company Address______________________________________Phone number________________
SS#_______________________Relationship to Card Holder:
Self
Spouse
Child
Other
BENEFIT ASSIGNMENT AND MEDICAL RECORD RELEASE
I authorize my insurance benefits to be made directly to the treating physician for services
rendered and all future claims for services rendered. I attest that the above insurance
information is accurate and that I am an eligible member. I also authorize the release of all
information necessary for the purpose of payment for services rendered for current and future
claims. I acknowledge that I have read the financial policy of the practice, I understand the
policy, and agree to give consent for treatment.
SIGNATURE OF PATIENT OR GUARDIAN_______________________________________________________
PRINTED NAME____________________________________________________DATE__________________
FINANCIAL POLICY
CASH POLICY - Pay for service is due in full at the time service is
provided in our office.
FOR PATIENTS WITH INSURANCE - We bill most insurance
carriers for you if proper paperwork is provided to us. We will also bill
most secondary insurance companies for you. Copayments and
deductibles are due at the time of service. Since your agreement with
your insurance carrier is a private one, we do not routinely research
why an insurance carrier has not paid or why it paid less than
anticipated for care. If an insurance carrier has not paid within 60
days of billing, professional fees are due and payable in full from you.
MEDICARE PATIENTS - We will bill Medicare for you. We will also
bill secondary insurance carriers for you. All copayments or
deductibles are due and payable at the time service is provided.
NONCOVERED SERVICES - Any care not paid for by your existing
insurance coverage will require payment in full at the time services
are provided or upon notice of insurance claim denial.
PERSONAL INJURY CASES - This office does not bill for auto
accident or other liability or lawsuit-related cases. You are responsible
for payment at the time of service. We do not accept liens.
MISSED APPOINTMENTS - In fairness to other patients and the
doctor, we required at least 24 hours’ notice to cancel appointments.
You may be charged for missed appointments or dismissed from the
practice.
MEDICARE PATIENTS: SIGNATURE ON FILE: I request payment
of authorized Medicare benefits be made on my behalf to the health
care professional providing any services furnished me. I authorize any
holder of medical information about me to release to the health care
professional’s billing staff any information needed to determine these
benefits or the benefits payable to related services.
ASSIGNMENT OF INSURANCE BENEFITS
I hereby assign all medical and/or surgical benefits, to include major
medical benefits to which I am entitled, private insurance, and any
other health plans, to the health care professional providing health
services to me. This assignment will remain in effect until revoked by
me in writing. A photocopy of this assignment is to be considered as
valid as an original. I understand I am financially responsible for all
charges whether or not paid by said insurance. I hereby authorize
said assignee to release all information necessary to secure the
payment.
I understand that my insurance is a contract between
myself and my insurance company. The healthcare
professionals’ billing staff will file my claim and will
work to resolve any problems obtaining payment from
my insurance company, but ultimately it is my
responsibility to contact my insurance company to
resolve any problems.
The patient is ultimately responsible for all
professional fees.
I have read, understood, and agree to the above
financial policy.
Patient or guarantor
signature________________________________
Date_________________________
PULMONARY CARE SPECIALISTS, PA
James P. Loftin, M.D.
Melissa L. Tompkins, M.D.
RELEASE OF MEDICAL RECORDS
I, ____________________________________________________
Date of Birth_________________________authorize
Doctor/practice name____________________________________
Address: ______________________________________________
______________________________________________________
To release my medical records to:
James P. Loftin, MD
Melissa L. Tompkins, MD
4333 N. Josey Lane
Suite 207
Carrollton, TX 75010
Phone no: 972-394-2971
Fax number 972-492-1261
Please include the following:
_________ labs
_______ radiology tests
_________ office notes
_______ spiro/pft
_________ other _________________________________
Patient’s Signature ________________________________
Printed Name: ________________________________
Date: _________________ Witness: __________________
I understand that I have the right to revoke this authorization, in writing, at any time, by sending written
notification to the practice. I understand that a revocation is not effective to the extent that the practice has
relied on this authorization in its actions. Also, a revocation is not effective if this authorization was
obtained as a condition of obtaining insurance coverage, as other law provides the insurer with the right to
contest a claim under the policy or the policy itself. I understand that information used or disclosed
pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be
protected by federal HIPAA privacy regulations. The practice will not condition my treatment, payment,
enrollment in a health plan or eligibility for benefits on whether I provide authorization for the requested
use or disclosure.
VII.
ACKNOWLEDGEMENT AND REQUESTED RESTRICTIONS.
By signing below, you acknowledge that you have received this Notice of Privacy Practices prior
to any service being provided to you by the Practice, and you consent to the use and disclosure of your
medical information as set forth herein except as expressly stated below.
I hereby request the following restrictions on the use and/or disclosure (specify as applicable) of my
information:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
I give my permission to speak with the following persons regarding my healthcare and any financial
issues related to my care:
Name______________________________________________________________________________
Phone number_____________________________________Relationship ______________________
Name______________________________________________________________________________
Phone number_____________________________________Relationship ______________________
Name______________________________________________________________________________
Phone number_____________________________________Relationship ________________________
Patient Name:
_____________________________________ Patient Date of Birth______________
(Please Print Name)
SIGNATURES:
Patient/Legal Representative: _______________________________________ Date: ________________
If Legal Representative, relationship to Patient: ______________________________________________
Witness (optional):
Date: ______________
_____________________________________________________________________________________________
HIPAA Policies and Procedures Manual
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