CHEST MEDICINE ASSOCIATES, P.S.C. Pulmonary Disease • Critical Care • Sleep Disorders
David H. Winslow, M.D. Richard W. Baker, M.D. Walter E. App, M.D. Loran P. Moore, M.D. George W. Boatwright, M.D. William O. Lacy, M.D. Carlos J. Ramirez-Icaza, M.D. David A. Hasselbacher, M.D. Ryan G. Wetzler, Psy.D.
Sleep Medicine Specialists welcome you to our practice! We have scheduled your initial appointment with Dr. ______________________ on__________________ at ____________ . Our office is located in the Watterson Medical Center, at 3430 Newburg Road, Suite 150. There is free and ample parking available. The first visit with us usually requires about an hour split between the nurse and your physician. This initial appointment is a preliminary evaluation to determine a probable diagnosis and initiate a plan of action. Any subsequent testing or follow up visits will be scheduled after this consultation. If you are unable to keep your appointment please call (502) 454-0755 at least 24 hours in advance to reschedule. The following information will help as you prepare for your visit. • Please complete the enclosed forms and bring them with you when you come in for your first visit. It is important that you complete all of the materials and bring them with you, as the physician will use the information as part of your evaluation. If you have questions regarding how to fill out the forms, please call 454-0755 X312. • If you have had sleep studies at another facility, please obtain a copy of your records and bring them with
you to your appointment. • When signing in the day of your appointment, the receptionist will ask you for your insurance card(s) to copy for our files. Our office will file your insurance claims. Referral authorizations by insurance carriers are the responsibility of the patient and should be obtained prior to your appointment date. Our office will obtain any authorization that may be needed for a procedure performed or ordered by our physicians. It is highly recommended that you check your insurance benefits to be sure services are covered and whether or not your deductible applies. • Co-payments are due at the time of service unless prior arrangements have been made. A receipt can be given to you showing your visit, diagnoses, return request, the visit charge and payment amount. If you do not have your co-pay at the time of service your appointment may be rescheduled. If you have any questions at any time, please do not hesitate to call our office. Thank you! We look forward to having you as our patient. The physicians and staff of Sleep Medicine Specialists
3430 Newburg Road Suite 150 Louisville KY 40218 502.454.0755
TO WATTERSON MEDICAL OFFICE From Interstate 264 West - Exit 15B, merge onto Newburg Road South (1703). Get in the middle lane and continue on Newburg Road South to Bashford Manor Lane traffic light. The Watterson Medical Center is on the right at the light. From Interstate 264 East - Exit 15, merge on to Newburg Road South (1703) by turning right. Get in the middle lane and continue on Newburg Road South to Bashford Manor Lane traffic light. The Watterson Medical Center is on the right at the light. From Interstate 65 North - Merge onto Interstate 264 East (The Watterson Expressway East) via Exit 131A. Take exit 15, merge on to Newburg Road South (1703) by turning right. Get in the middle lane and continue on Newburg Road South to Bashford Manor Lane traffic light. The Watterson Medical Center is on the right at the light. From Interstate 65 South - Merge onto lnterstate 264 East (The Watterson Expressway East) via Exit 131A. Take exit 15, merge on to Newburg Road South (1703) by turning right. Get in the middle lane and continue on Newburg Road South to Bashford Manor Lane traffic light. The Watterson Medical Center is on the right at the light. TO GREENWOOD ROAD OFFICE From Interstate 264 West - Exit Fort Knox/Dixie Highway South. Continue about five miles down Dixie Highway. Take a right on Greenwood Road. (Walgreen’s is on the corner). Our office is located ½ block down on the left. From Interstate 265 South - Exit onto Dixie Highway north. Continue about 3 miles on Dixie Highway. Turn left on Greenwood Road. (Walgreen’s Pharmacy is on the corner). Our office is located ½ block down on the left.
We look forward to having you as our patient! If you have any questions, or need help finding our office, Please feel free to call: 502.454.0755 X312
Chest Medicine Associates, PSC Sleep Medicine Specialists, PSC Acquaintance Form
Date: __________________________________ Person who sent you: _____________________
Patient Information (Please Print) Name of Patient: _____________________________________________________________________Male___Female___ Home Address: _______________________________________________________________Zip Code________________ Marital Status (circle one): Single Race (circle one): Caucasian
Asian
Married Black
Divorced Hispanic
Separated
Partner
American Indian Other __________________________
Ethnicity Home Phone :(
Widowed
Preferred Language ) _______________ Work Phone :(
) ________________ Cell Phone :(
) _________________
E-Mail Address: ______________________________________________ May we contact you by E-Mail: Yes or
No
Age: ________Date of Birth: _____________________Social Security #:________________________________________ Employment (if applicable):__________________________Address:___________________________________________ Nearest Relative (not at same address)_______________________________Relationship:_________________________ Address_______________________________________________________ Phone :(
)__________________________
Spouse/Parent/Guardian Information Name of spouse/parent/guardian: _______________________________Relationship:____________Date of Birth: _______ Social Security #:_____________Employment: _______________________________Work Phone ( Insurance Information
) ______________
Please Give Card(s) To Receptionist
Name of PRIMARY Company: ________________________________Address__________________________________ Name of Insurer or Subscriber: ______________________________ID#:____________________Group#:______________ Soc Sec #:_________________Subscriber’s Date of Birth: _______________Relationship to Patient: _________________ Name of Secondary Insurance Company: _________________________Address__________________________________ Name of Insurer or Subscriber: ______________________________ID#:____________________Group#:______________ Soc Sec #:_________________Subscriber’s Date of Birth: _______________Relationship to Patient: _________________ Authorization: I hereby authorize the release of medical information or other information acquired during the course of examination and treatment to Medicare, insurance carriers, physicians, or my legal representatives. I understand my medical records may be accessed by any physician or employee of this practice for legitimate clinical, billing or administrative purposes. I hereby request payment of benefits from all insurance carriers to Chest Medicine Associates, PSC/Sleep Medicine Specialists. I understand I am responsible for and will pay any amount not covered by insurance carriers. I understand I may be charged a $25.00 fee for not cancelling/rescheduling an appointment with a physician within 24 hours prior to scheduled time. I consent to receive care provided by the physicians and staff of Chest Medicine Associates/Sleep Medicine Specialists.
Date
Signature
Relationship
I have received a copy of the Chest Medicine Associates Notice of Privacy Practices. I understand that Chest Medicine Associates has the right to change its Notice of Privacy Practices from time to time and that I may contact Chest Medicine Associates at any time to obtain a current copy of the Notice of Privacy Practices.
□ I acknowledge that the HIPAA privacy notice has been made available to me by Chest Medicine Associates, PSC. □ I give my permission to discuss my medical records with the family member/friend listed:
Signature
Date
Patient Name: ______________________
Patient D.O.B.: ________________________
How did you hear about us? (Please check one) Physician Referred Television
Phone Book
Former Patient
Magazine Ad
Friend/Family
Website
Health Fair
Radio
Other (describe) ___________________
Have you been previously diagnosed with sleep apnea? Has anyone told you that you snore loudly? Have you awakened with a dry “cotton mouth? Has your family told you that you quit breathing at night? Have you even awakened at night with gasping, coughing choking, or respiratory discomfort? Do you have morning headaches?
YES
NO
__________________________________________________________________________________________ Have you had problems with being sleepy or tired during the day? Do you have difficulty falling sleep at night? Do you have difficulty staying asleep or being restless during sleep? Do you have difficulty “slowing down” or “turning off” your mind while trying to sleep?
YES
NO
A poor night’s sleep make you: Yes No Depressed
A poor night’s sleep negatively affects your: Yes No Ability to concentrate
Anxious
Memory
Irritable
Ability to work
Fatigued
Mood
YES Do you have discomfort in your legs while trying to fall asleep?
NO
Have you ever had the feeling of being paralyzed while going to sleep or awakening? Have you ever had visual hallucinations or dream-like mental image while falling asleep? Have you ever experienced sudden physical weakness during strong emotions? (Such as legs going limp, mouth dropping open during laughter or anger)
YES NO
Were you sleepy in middle school or as a teenager?
If yes to the previous question, does moving/kicking your legs or walking give you relief?
Circle all that apply during sleep DO YOU: sleep walk talk in your sleep grind your teeth eat unknowingly physical act out your dreams
wake up screaming frequent nightmares
Circle all that apply DO YOU: read in bed work in bed argue in bed watch TV in bed worry in bed use sleep medication work a rotating or night shift nap during the day
Patient Name: ______________________
Patient D.O.B.: ________________________
Epworth Sleepiness Scale How likely are you to doze off or fall asleep in the following situations in contrast to just feeling tired? Even if you have not done some of these things recently, try to work out how they would have affected you. Please use the following scale to choose the most appropriate number for each situation.
0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing Situation
Chance of Dozing
Sitting and reading Watching TV Sitting inactive in a public place (in a theatre, meeting, etc.) As passenger in a car for an hour without a break Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after lunch without alcohol In a car, while stopped for a few minutes in traffic Total Score
Weekdays Time you go to bed Time you get up Average hours of sleep per night
Weekends
________
CHEST MEDICINE ASSOCIATES / SLEEP MEDICINE SPECIALISTS MEDICAL HISTORY QUESTIONNAIRE
Date: Name:
Date of Birth:
Who Sent You?
Why?
Family Doctor:
Pharmacy Name & Number:
List all other doctors that you see: Previous Medical History (check all that apply) □
A fib (irregular heartbeat)
□
Emphysema
□
Obesity (over weight)
□
Anemia
□
Fibromyalgia
□
Osteoporosis (bone loss)
□
Anxiety
□
GERD
□
OSA (sleep apnea)
□
Asthma
□
Glaucoma
□
Osteoarthritis
□
Bronchitis
□
Hashimoto Thyroiditis
□
Pulmonary Embolism
□
Cancer
□
Hypertension (high BP)
□
Respiratory Failure
□
Cardiomegaly(enlarged heart)
□
Hyperthyroidism
□
Rheumatoid Arthritis
□
Cardiomyopathy (weak heart)
□
Hypothyroidism
□
RLS (restless legs)
□
CHF (Congestive Heart Failure)
□
Interstitial Lung Disease
□
Sarcoid
□
Chronic Pain
□
Kidney Disease
□
Seasonal Allergies
□
COPD
□
Liver Disease
□
Seizure Disorder
□
Coronary Artery Disease
□
Lung Cancer
□
Sinusitis
□
Depression
□
Lung Nodule (spot on lung)
□
TB (positive skin test)
□
Diabetes
□
MI (heart attack)
□
Ulcer
□
DVT (blood clot)
□
Narcolepsy
□
Valvular Heart Disease
□
Dyslipidemia (high cholesterol)
□
Neuropathy (extremity discomfort)
□
Other_______________________
□
Coronary Artery Bypass Graft
□
Knee Surgery
Previous Surgical History (check all that apply) □ Adenoidectomy (adenoid removal) □
Appendectomy (appendix removal)
□
Gastric Bypass
□
Lap Banding
□
Back Surgery
□
Heart Catherization
□
Lung Surgery
□
C-Section
□
Heart Valve Replacement
□
Sinus Surgery
□
Cataract Surgery
□
Hernia Repair
□
Tonsillectomy (tonsil removal)
□
Cholecystectomy (gallbladder)
□
Hip Surgery
□
Thyroid Surgery
□
Colon Surgery
□
Hysterectomy
□
Vascular Stent
□
Other_______________________
Immediate Family History (check all that apply) □ Anxiety Disorder
□
Excessive Daytime Sleepiness
□
RLS (restless legs syndrome)
□
Asthma
□
Heart Problems
□
Seizure Disorder
□
Cancer
□
Hypertension (high blood pressure)
□
Snoring
□
Congestive Heart Failure
□
Lung Cancer
□
Stroke
□
COPD
□
MI (heart attack)
□
Thyroid Problems
□
Depression
□
Narcolepsy
□
Tuberculosis
□
Diabetes
□
Obesity (over weight)
□
Other_______________________
□
Emphysema
□
OSA (sleep apnea)
____________________________
Name Social History (check all that apply) 1.
Marital status: _______________________
2.
Do you currently smoke? YES
3.
If you do not currently smoke, have you ever? YES
4.
Do you drink alcohol of any kind? YES
5.
Do you drink caffeinated beverages? YES
6.
Have you ever used marijuana, cocaine, or other illicit drugs? YES
7.
Do you exercise regularly? YES
8.
Have you recently traveled outside or within the United States? YES
9.
Have you ever been in an environment (work or other) where you were exposed to any of the following: (circle all that apply) Coal Dust
Asbestos
Occupation: __________________________________________________________________
NO
If yes, for how long?_____ years NO
NO
NO
If yes, for how long?_____ years How much?_____ packs per day
If yes, how many days per week? _____ How many drinks per day? _____ NO
If yes, how many days per week? _____ How many drinks per day? _____ NO
If YES, which drug and how often?________________________
If yes, how many days per week? _____ How long each day? _____
Gas Fumes
NO
Chemical Fumes
Review of Systems for Past 6 Months (check all that apply)
If yes, where did you travel to? _________________________ Large Amounts of Dust
Shortness of breath on: □ Walking several blocks □ Climbing one flight of stairs □ Upon laying down
□ □ □ □ □
General: Fever Chills Night sweats Weight loss Weight gain
□ □ □ □ □ □
HEENT: Spots before the eyes Blurred vision Earaches Sinus trouble Persistent hoarseness Difficulty swallowing
□ □ □ □ □
Respiratory: □ Chest pain □ Coughed up blood □ Chronic or frequent cough Wheezing in response to: □ Animals □ Cold Air □ Exercise □ Perfume □ Pollen Current Medications (including over the counter meds) Medication
How much?_____ packs per day
Dose /
□ □ □ □ □ □ □ □ □ □ □
Silica
Birds
Wild Game
□ □
Musculoskeletal: Swelling of joints Recurrent back pain
Cardiovascular: Fluttering of heart High blood pressure Low blood pressure Light headedness Swelling of hands, feet or ankles
□ □ □ □ □
Neurologic: Seizures Numbness Tingling Frequent or severe headaches Dizziness
Gastrointestinal: Abdominal pain Heartburn Bloating Nausea Vomiting blood Bowel disease Blood in bowel movements Hemorrhoids Genitourinary: Pain on urinating Blood in urine Frequent urination at night
□
Integumentary: Skin rash
Medication
Dose /
□ □ □ □ □
Sleep: Difficulty going or staying asleep Loud snoring Stop breathing when you sleep Sleepy while driving Problems with legs jerking while going to sleep or trying to sleep
Medication
Dose /
/
/
/
/
/
/
/
/
/
/
/
/
Are you allergic to any medications? If so, please list: Are your childhood immunizations up to date?
Date of most recent flu vaccine:
Please list all doctors you would like your information released to: Name
Specialty
Name
Specialty
Name
Specialty
Date of most recent pneumonia vaccine:
