Sleep Disorder Evaluation Template

Sleep Disorder Evaluation Patient Name Pt DOB
Date Chief complaint/Reason for consult Referring MD

Start time
Stop time
Medications History of Present Illness Patient is Nonverbal. History obtained from Family Medical records
Medication list reviewed
Medications reconciled with Nursing
Home or Hospital discharge
Information 46
Patient takes antidepressants, benzodiazepines, stimulants, narcotics, anti-seizure medications, alcohol or recreational drugs
Changes as follows 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
Allergies Difficulty falling asleep or staying asleep Leg jerks while sleeping
Allergy List reviewed Hypnogogic or Hynopompic symptoms Restless legs symptoms
No drug allergies Sudden muscle weakness associated with strong emotions Recent weight gain of >10 pounds
No food allergies Estimated number of hours of sleep/night # Caffeinated beverages consumed/day
Social History Review of Systems
Never Smoker See HPI WNL
Tobacco ____ # Packs X ____ # Yrs Constitutional Fatigue, malaise, fever/chills, weight loss, change in appetite
Quit Eyes Vision changes, New pain, Scotomas
Patient has tried Nicotine replacement ENT/mouth Nose bleeds, dental caries, dental abscesses, jaw pain
Buproprion or nortriptyline Resp Dyspnea, Cough, Phlegm, Hemoptysis, Wheeze, Witnessed Apnea
Nicotine receptor blockade CV Chest pain, diaphoresis, ankle edema, PND, syncope
Daily, occasional and ex-smokers are more GI Emesis, dysphagia, GERD, abdominal pain, diarrhea, melena
likely to be hazardous drinkers
GU Change in urinary habits, hematuria, dysuria
Alcohol use
Musc Myalgias, recent trauma, bony fractures, arthralgias, joint swelling
______ Drinks per day week
Hazardous drinking Skin/breasts Rashes, new masses or skin lesions, increased sensitivity to sun
NIAAA (National Institute on Alcoholism Neuro Seizures, episodic or chronic muscle weakness
and Alcohol Abuse guidelines) Endo Hair loss, polydipsia
Men > 14 drinks per week OR Heme/lymph Bleeding gums, unusual bruising, swollen lymph nodes
> 4 drinks per day Allergy/Immun Sinus probs, recurrent infections
Women > 7 drinks per week OR
>3 drinks per day Psych Mood changes, agitation, psychosis, delirium, dementia
Recreational drug use Occupational History Shift work If yes, describe work schedule
Inhalational Injectable Ingestible
Drug dependence
Narcotics Benzodiazepines
Family Medical History Past Medical History Surgical History
Asthma Asthma Deviated septum Denies surgical history
Congestive Heart Failure Cerebral Artery Disease Head and neck cancer ENT surgeries
COPD Congestive Heart Failure Insomnia Rhinoplasty
Coronary Artery Disease COPD Narcolepsy Jaw surgery
Premature Onset
Coronary Artery Disease Nasal polyps Polypectomy
Malignancy
Narcolepsy GERD Obstructive Sleep Apnea Uvulopalatopharyngoplasty
Neuromuscular Disease Hepatic Dysfunction Radiation to neck or head
Obstructive Sleep Apnea Hypertension Restless Legs Syndrome
Pancreatitis Neuromuscular weakness Periodic Leg Movement Disorder
Peripheral Artery Disease PAH Swallowing disorder
Renal Dysfunction Peripheral Artery Disease
Thrombotic disorder Rheumatoid arthritis
Thyroid Disease Sarcoidosis
Scleroderma
Seizure Disorder
Thyroid Disease Vaccines Flu Pneumo BCG Tetanus Pertussis Varicella
©MB and RR 2006-2008 Revised 6Feb08 Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures
Sleep Disorder Evaluation Patient Name Pt DOB
Prior Diagnostic Data Exam
ECHO/Stress Test GeneralAlert Vitals T P R BP Sats %
Sleep Study ENT Nasal mucosa Dentition Oropharynx Mallampati I II III IV
Full night Neck Normal to palpation Thyroid No JVD
Split night Resp Clear to auscultation Dullness to percussion No respiratory distress
Apnea/Hypopnea Index ___ No chest wall defects Decreased fremitus Bronchial breath sounds
Absence of intercostal respiratory retractions Egophony (E to A change)
Multiple Sleep Latency Test CV Clear S1 S2 No murmur No gallop No rub Peripheral pulses No peripheral edema

Maintenance Wakefulness Test GI No palpable masses Liver and spleen not palpable No hepatojugular reflux
Lymph No lymphadenopathy
Musc Tone Gait
Extrem No clubbing No cyanosis
Skin No rashes, ecchymoses, nodules, ulcers
Neuro Oriented 58(Pts with Community Acquired Bacterial Pneumonia) Affect
Plan Impression
Pneumonia vaccine Epworth Sleepiness Score
Influenza vaccine

Smoking cessation aids
Labs

12-lead EKG
Echocardiogram
CXR
Inspiratory and Expiratory
CT of Chest
Pulmonary Function Testing
Overnight Polysomnography
MSLT
Maintenance Wakefulness Test
CPAP
BiPAP
Supplemental Oxygen

Follow Up Signature
cc:
Patient has completed advanced health care directives47 HCPOA is
Code Status Patient is a FULL CODE DO NOT ATTEMPT RESUSCITATION
©MB and RR 2006-2008 Revised 6Feb08 Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures

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Sleep Disorder Evaluation Patient Name Pt DOB

Date Chief complaint/Reason for consult Referring MD

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