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🌙 Get Ready for Your
First Sleep Consultation

To make the most of your upcoming consultation, please complete these short forms in advance.
This helps us understand your sleep patterns and provide the best care tailored to you.

First Name *

Last Name *

Email *

Date of birth

Medical History

CARDIOVASCULAR HISTORY?

Yes

No

CARDIOVASCULAR DIAGNOSIS? Cardiovascular diagnoses:

CARDIOVASCULAR DIAGNOSIS? Cardiovascular diagnoses - Notes

HISTORY OF HYPERTENSION?

Yes

No

RESPIRATORY/ PULMONARY DIAGNOSIS?

RESPIRATORY/ PULMONARY DIAGNOSIS? - Notes

DIAGNOSED SLEEP APNEA?

No

Yes

Yes- with CPAP or other sleep device

PREGNANCY STATUS?

N/A

Not- Pregnant

Post- Menopausal

Hysterectomy

Pregnant

HISTORY OF DIABETES?

No

Yes- Type I

Yes- Type II

DIABETIC TREATMENT?

HISTORY OF RENAL DISEASE?

Yes

No

RENAL DIAGNOSIS?

N/A

Renal Insufficiency

Urinary Tract Infection

Nephritis

Chronic Kidney Disease (CKD)

Dialysis

Other

RENAL DIAGNOSIS? - Notes

HISTORY OF NEUROLOGICAL/MUSCULOSKELETAL DISORDERS?

No

Yes

NEUROLOGICAL/ MUSCULOSKELETAL DIAGNOSIS?

NEUROLOGICAL/ MUSCULOSKELETAL DIAGNOSIS? - Notes

PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING RELATED TO THIS DISORDER

HISTORY OF GASTROINTESTINAL ISSUES?

Yes

No

GASTROINTESTINAL DIAGNOSIS?

GASTROINTESTINAL DIAGNOSIS? - Notes

HISTORY OF BLOOD/ BLEEDING DISORDERS?

Yes

No

BLOOD/ BLEEDING DIAGNOSIS:

BLOOD/ BLEEDING DIAGNOSIS: - Notes

HISTORY OF CANCER?

Yes

No

CANCER DIAGNOSIS?

CANCER DIAGNOSIS? - Notes

PSYCHIATRIC HISTORY?

Yes

No

PSYCHIATRIC DIAGNOSIS?

PSYCHIATRIC DIAGNOSIS? - Notes

SURGICAL HISTORY?

Yes

No

ANYONE IN YOUR FAMILY HAVE PROBLEMS WITH ANESTHESIA

Yes

No

Other

ANYONE IN YOUR FAMILY HAVE PROBLEMS WITH ANESTHESIA - NOTES

PROBLEMS WITH ANESTHESIA

Yes

No

Other

PROBLEMS WITH ANESTHESIA - NOTES

PLEASE LIST ALL SURGICAL PROCEDURES & YEAR

TOBACCO HISTORY?

No- Never smoked

No- quit smoking more than 5 years ago

No- quit more than 10 years ago

Yes- Currently smokes less than 2 packs a day

Yes- currently smokes more than 2 packs a day

SOCIAL HISTORY

MEDICAL RECORDS PROVIDED?

Yes

No

ALCOHOL HISTORY

No

Yes- Socially

Yes- More than 3 drinks a day

RECREATIONAL DRUG USE

RECREATIONAL DRUG USE - Notes

LIST ALL MEDICATIONS AND DOSES

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