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dreams of a better tomorrow

While Diagnostic Sleep Studies are by physician’s appointment only, you can help streamline
the process by downloading and completing
our Sleep Study Appointment Forms
prior to your visit.

Our forms help identify symptoms for your physician’s
review and help us to prepare for your visit ahead
of time. We can accomodate any sleep cycle,
or special requirements you might have.

Select the link below to download
our appointment forms.

Please download and complete the following forms prior to your visit. Forms are available individually below, or you can download a complete file archive from the link above.

Patient Registration Form
If you have never visited us before, please complete this form prior to your appointment.


Patient Testing and Cancellation Policy
Please be aware of our test result and cancellation policies.

Patient Rights and Responsibilities
Please be aware of your rights and responsibilities as a patient of Sleep Diagnostics of America.

Patient Preparation Forms
A step-by-step instruction to help you prepare for your sleep test evaluation.
Clear Lake, La Porte, The Heights, Texas City


Patient Satisfaction Survey

Our company strives to provide the best service available for you. In order for us to evaluate our success in achieving our goals of providing the best service and test results, please take a few moments to fill out this form and let us know how we did.




HIPAA Acknowledgement Form
The Health Insurance Portability and Accountability Act (HIPAA) is a federal law (Public Law 104-191), passed by Congress in 1996 that ensures the privacy of an individual's health information and provides security for electronic data sharing of protected health information.

Electronic Communications Agreement
Allows Sleep Diagnostics of America to contact our patients electronically via email, text or phone.


What to expect during your overnight sleep evaluation
Please download our detailed guide on overnight sleep studies to help prepare you for your evaluation.


Sleep History Questionnaire
Please download and complete our sleep history questinonaire, or fill out the form below.


sleep history questionnaire

Today's Date*:
 

Patient Information
Name*:
Email*:
DOB*: Age*:
Height*: Weight*:
 

Epworth Sleepiness Scale
Please rate the chance of dozing in the following situations:
While Sitting/Reading
While Watching TV
Sitting in public (e.g. while in a theatre or meeting)
As a passenger in car for an hour or so
Lying down to rest in the afternoon/nap
While sitting and talking to someone
Sitting after lunch without alcohol
While in a car, stopped for a few minutes in traffic

Medical History
Do you currently have, or have you ever had?
 
Allergies
Asthma
Diabetes
Heart Problems
High Blood Pressure
Laser Surgery for Snoring
Multiple Sclerosis
Nasal Surgery
Nocturnal Esphangeal Reflux
Parkinson's
Scoliosis
Stroke
Swelling of Hands or Feet
COPD
Congestive Heart Failure
Coronary Artery Disease
Periodic Limb Movement Disorder
Restless Leg Syndrome

Have you had any recent weight changes? If so, how much

Do you have any other medical problems not listed?

List Medications Dosage Times Reason for Medication

List all Surgeries Years of Surgeries Any Medical Allergies

Sleep Concerns/Problems
What type of sleep problems do you have? How long have you had sleep problems?

Social History
What is your present occupation:
Hours worked:
Are you a shift worker?
Do you drive a vehicle for work?
Do you smoke?
If yes, how many years?
How many packs/day?
 
 
Do you drink caffeinated beverages?
How many per day?
Do you drink alcoholic beverages?
How often?

Do you exercise regularly?
How often?
Do you have any unusual eating habits?
If yes, please explain?

Sleep History On Weekdays On Weekends
What is your usual bed time?
What is your usual wake up time?
If you take naps, how often?
If you take naps, how long?
How long does it take you to fall asleep
Do you awaken feeling refreshed?

I sleep in a bed
I share the bed with a partner
I snore
I sleep on my
I have choking sensations while sleeping
I talk in my sleep
I gasp for air in my sleep
I grind my teeth
I have restless legs
I have PLMD (twitching, itchy legs)
I have night sweats
I awaken often during the night
My pets sleep in my bedroom
I awaken with dry mouth
I have a lack of sexual drive
I feel sleepy during the day
I fight bouts of sleep while driving
I have trouble remembering things
I have feelings of depression
I have anxiety
Weak knees when startled/laughing
I sleep in a recliner
I watch TV while in bed
I have trouble sleeping on my back
I have trouble breathing through my nose
I stop breathing while sleeping
I walk in my sleep
I toss and turn in my sleep
I have vivid dreams while falling asleep
I have indigestion, heartburn or gas
I have PTSD (Post Traumatic Stress)
I have night terrors
I awaken to urinate
I feel paralyzed upon awaking
I awaken with headaches
I have impotence
I fight bouts of sleep during the day
I've been in a wreck due to sleepiness
I have a lack of concentration
I am irritable
I am under the care of a Cardiologist
I bang my head while sleeping