THIS IS AN ONLINE FORM. DO NOT PRINT
THIS IS NOT A PRINTABLE FORM. PLEASE FILL ALL THE FIELDS AND HIT SUBMIT AT THE END.

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Today's Date:

PATIENT INFORMATION

Mr.       Mrs.       Miss.       Ms.

Patient's Last Name:*
First Name:*
Middle Name:
Is this your legal name?*
If not, what is your legal/former name?
Sex:* M F
Date of birth:*
Age:*
SSN:
Marital Status: Single       Married       Divorced       Separated       Widowed
Race:
American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian
Other Pacific Islander
White
Refuse to Report

Preferred Language:

Ethnicity:
Hispanic/Latino
Non-Hispanic /Latino

Other:

ADDRESSES HOME & WORK
Home Address:*
City:*
State:*
Zip code:*
Home Phone Number:*
Email:*
Employer Address:
City:
State:
Zip code:
Occupation/Position:
Employer/Business Phone Number:
HOW DID YOU HEAR ABOUT OUR CLINIC?

Online / Internet

Insurance Plan

Hospital

Close to home/work

Family/Friend :

Other:

Where you referred to us by your doctor?      Y      N

If yes, please write your doctor's name and their phone number:

INSURANCE INFORMATION
Define Coverage Type:
Self-Pay (no insurance)    Insurance    Other Insured (spouse)    Workers Comp
Insurance carrier: ID:
Secondary Insurance carrier (if applicable): ID:
Other Person Responsible for my bill:
Name: Relationship to patient:
Date of Birth: Contact Phone Number:
IF A MINOR ONLY:
Fathers Name: Mothers Name:
IN CASE OF EMERGENCY
Name of local friend or relative (not living with you) Relationship to patient: Phone Number:
New Patient Packet
Page - 1

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Name:

DOB:

Date:

Welcome to our office or welcome back, We want to provide you with the best possible care, so please take a few moments to complete the following pages. Thank you.

What is The main urologic issue you would like to discuss?

Do you have any other urologic issues you would like addressed?

Please list any medical conditions you have (high blood pressure, diabetes, etc.):

1.

2.

3.

4.

5.

6.

Please list any prior surgeries or procedures:

1.

2.

3.

4.

Date of surgery/procedure:

Patient Questionnaire(Male)
Page - 2

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Name:

DOB:

Please list any current medications/herbal supplement:

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Dose:

Please list any medications you are allergic to:

1.

2.

3.

4.

Reaction:

Please list any serious illness in your family:

Relative:

Relative:

Relative:

 

Illness:

Illness:

Illness:

Patient Questionnaire(Male)
Page - 3

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Name:

DOB:

MALE PATIENTS ONLY:

Do you have difficulty achieving or maintaining an erection?

Yes    No

Have you ever had an abnormal PSA result?

Yes    No

Ave you every had a prostate biopsy?

Yes    No

If yes, please list biopsy date(s) and result(s):

Ashkenazi Jewish Ancestry?

Yes    No

Have you or any one in your family been diagnosed with metastatic prostate cancer?

Yes    No

Have you or any one in your family been diagnosed with ovarian cancer?

Yes    No

Have you or any one in your family been diagnosed with pancreatic cancer?

Yes    No

Have you or any one in your family been diagnosed with breast cancer <50 years old?

Yes    No

Have you or any one in your family been diagnosed with any other type of cancer(s)? If yes, please indicate what type:

Yes    No

*******************************************************************************

Please indicate your current marital status:

Single       Married       Separated       Divorced       Widowed       Domestic Partner

On average, how many alcoholic beverages do you have in a week?

Did you ever smoke on a regular basis?     Yes /   No

If yes, how many packs a day? For how many years?

Are you still smoking?    Yes /   No    If no, when did you quit?

Have you had a colonoscopy in the last 5 years?     Yes /   No

Do you have an Advanced Care Plan in place?     Yes /   No /   No (my cultural and/or spiritual beliefs preclude me from having a discussion regarding advance care planning)

If yes…     Living Will     Do Not Resuscitate     Power of Attorney

Patient Questionnaire(Male)
Page - 4

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REVIEW OF SYSTEMS

Do you or have you recently had any problems related to the following?

Please mark the appropriate box. If your answer is Yes, please explain in the space provided.

Name:

DOB:

Constitutional

Fever Yes /   No
Chills Yes /   No
Weight Loss Yes /   No
Other

Gastrointestinal

Abdominal pain Yes /   No
Nausea/vomiting Yes /   No
Constipation/diarrhea Yes /   No
Other

Eyes

Blurred vision Yes /   No
Glaucoma Yes /   No
Other

Musculoskeletal/Neck

Back pain Yes /   No
Leg pain Yes /   No
Muscle pain Yes /   No
Other

Ears/Nose/Throat

Difficulty hearing Yes /   No
Sinus problems Yes /   No
Difficulty swallowing Yes /   No
Other

Neurological

Migraines Yes /   No
Dizzy spells (Lightheadedness) Yes /   No
Numbness/tingling Yes /   No
Other

Respiratory

Shortness of breath Yes /   No
Chronic cough Yes /   No
Other

Integumentary

Skin rash Yes /   No
Skin lesion(s) Yes /   No
Breast (lumps, etc.) Yes /   No
Other

Cardiovascular

Chest pain Yes /   No
Heart attack Yes /   No
High blood pressure Yes /   No
Other

Allergic/Immunologic

Hay fever Yes /   No
Environmental allergies Yes /   No
Food allergies Yes /   No
Other

Genitourinary

Frequent urination Yes /   No
Wake to urinate Yes /   No
# of times
Slow stream Yes /   No
Push to urinate Yes /   No
Retaining urine Yes /   No
Painful urination Yes /   No
Urinary tract infection Yes /   No
Incontinence Yes /   No
# of pads per day
Sexual activity Yes /   No
Low libido Yes /   No
Erectile dysfunction Yes /   No
Premature ejaculation Yes /   No
Difficulty reaching orgasm Yes /   No
Other

Hematologic/Lymphatic

Blood clotting disorder Yes /   No
Anemia Yes /   No
Swollen glands Yes /   No
Other

Endocrine

Excessive thirst Yes /   No
Too hot/cold Yes /   No
Tired/sluggish Yes /   No
Other

Psychological

Depression Yes /   No
Anxiety Yes /   No
Other


Physician Signature (Your Name is Your Electronic Signature)


Date

Patient Questionnaire(Male)
Page - 5

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URINARY SYMPTOM SCORE

Last Name*:

First Name*:

Date*:

From the scale 0 to 5, please select the number that best describes your response for each question and fill in your score in the far-right box for all SEVEN questions.

  1. Incomplete emptying: Over the past months(s) how often have you had the sensation of not emptying your bladder completely after you finished urinating?

  2. Not at All Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always Your Score

    0

    1

    2

    3

    4

    5

  3. Frequency: Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating?

  4. Not at All Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always Your Score

    0

    1

    2

    3

    4

    5

  5. Intermittency: Over the past month, how often have you found that you stopped and started again several times when you urinated?

  6. Not at All Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always Your Score

    0

    1

    2

    3

    4

    5

  7. Urgency: Over the past month, how often have you found it difficult to postpone urination?

  8. Not at All Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always Your Score

    0

    1

    2

    3

    4

    5

  9. Weak-stream: Over the past month, how often have you had a weak stream?

  10. Not at All Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always Your Score

    0

    1

    2

    3

    4

    5

  11. Straining: Over the past month, how often have you had to push or strain to begin urination?

  12. Not at All Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always Your Score

    0

    1

    2

    3

    4

    5

  13. Nocturia: Over the past month or so, how many times did you get up to urinate from the time you went to bed until the time you got up in the morning?

  14. Not at All 1 time 2 time 3 time 4 time 5 or more times Your Score

    0

    1

    2

    3

    4

    5

Add up your score for total AUA score=

Quality of Life Due to Urinary Symptoms: If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that? Please select your answer below.

Delighted

Pleased

Mostly satisfied

Mixed

Mostly dissatisfied

Unhappy

Terrible

Would you be interested in Learning about a minimally invasive option that could allow you to avoid or discontinue enlarged prostate medications?

Yes    No

Patient Questionnaire(Male)
Page - 7

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Patient Name:

THE IIEF-5 QUESTIONNAIRE (SHIM)

Please select the response that best describes you for the following five questions.

Over the past 6 months:

  1. How do you rate your confidence that you could get and keep an erection?

  2. Very Low Low Moderate High Very High Your Score

    1

    2

    3

    4

    5

  3. When you had erections with sexual stimulation, how often were your erections hard enough for penetration?

  4. Almost never or never A few times (much less than half the time) Sometimes (about half the time) Most times (much more than half the time) Almost always or always Your Score

    1

    2

    3

    4

    5

  5. During sexual intercourse, how often were you able to maintain your erection after you had penetrated your partner?

  6. Almost never or never A few times (much less than half the time) Sometimes (about half the time) Most times (much more than half the time) Almost always or always Your Score

    1

    2

    3

    4

    5

  7. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?

  8. Extremely difficult Very difficult Difficult Slightly diffucult Not diffucult Your Score

    1

    2

    3

    4

    5

  9. When you attempted sexual intercourse, how often was it satisfactory for you?

  10. Almost never or never A few times (much less than half the time) Sometimes (about half the time) Most times (much more than half the time) Almost always or always Your Score

    1

    2

    3

    4

    5

Total Score:

1-7
Severe ED
8-11
Moderate ED
12-16
Mild-moderate ED
17-21
Mild ED
22-55
No ED
Patient Questionnaire(Male)
Page - 8

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MEDICAL INFORMATION RELEASE FORM

This form is to allow Comprehensive Urology Medical Group, its physicians, and its staff to release the stated medical information to designated family and/or friends.

What is The main urologic issue you would like to discuss?

I, hereby authorize Comprehensive Urology Group to provide information about my medical information to family or friends that I name in this document. Comprehensive Urology may release information relating to the items checked below.

Please list the persons allowed to receive information and your relationship.

1.

2.

3.

4.

5.

Information to be released:

Please list any medical conditions you have (high blood pressure, diabetes, etc.):

Appointment information*

Lab results*

General health inquiry*

Surgery pre-op and post-op instructions*

Request copies of medical records*

Other*

By checking the item(s) above, I acknowledge that I have authorized Comprehensive Urology Medical Group to release such information. I have read and reviewed the foregoing release and understand its contents.

I acknowledge that Comprehensive Urology Medical Group is hereby released from any all claims, demands, or liabilities arising out of or in any way related to the disclosure of the information above.

I also have the right to change or revoke this request at any time.


Print Patient's Name:*


Patient's Signature* (Your Name is Your Electronic Signature)


Date

Patient Questionnaire(Male)
Page - 9

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AUTHORIZATION TO PAY MEDICAL & SURGICAL BENEFITS DIRECTLY TO ATTENDING PHYSICIAN

 

I hereby authorize to make payments directly to

Insurance Company Name

Kiarash Michel, M.D., Robert Sanford, M.D., Dino Deconcini, M.D., Evan Rosen, M.D. and/or Comprehensive Urology Medical Group for all surgical and medical expense benefits otherwise payable to me for this period of treatment. I understand that I am financially responsible for all charges not covered by my insurance benefits.

I also authorize release of my records to the insurance company for purpose of billing.


Print Patient's Name:*


Patient's Signature* (Your Name is Your Electronic Signature)


Date

Patient Questionnaire(Male)
Page - 10

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ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

 

By signing this form, you acknowledge receipt of the Notice of Privacy Practices.

Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to read it in full.

Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice.

I, have received a copy of this office's Notice of Privacy Practices.


Print Patient's Name:*


Patient's Signature* (Your Name is Your Electronic Signature)


Date

 

 

For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgment could not be obtained because:

Individual refused to sign.

Communication barriers prohibited obtaining the acknowledgement.

An emergency situation prevented us from obtaining acknowledgement.

Other (Please specify

 

 

Patient Questionnaire(Male)
Page - 11

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Patient Name*:

Date of Birth*:


FINANCIAL POLICY

Welcome to Comprehensive Urology Medical Group (CUMG). We are committed to providing you the best urological care possible. For your convenience we have outlined our office financial policy. Kindly review and sign and/or initial in the designated spaces below, indicating you understand the policies. Please feel free to speak with our staff member should you have any questions.

All patients must complete our "Patient Information Form" prior to seeing the doctor.

1. Co-payments. All co-payments need to be paid at the time of service. This arrangement is part of your contract with your insurance company. We accept cash, checks, and most major credit cards. If your referring physician has indicated an alternative payment plan please take the time to notify the business office representative.

Please Initial:

2. Insurance. If your insurance changes, please notify us immediately so we can make the appropriate changes to help you receive your maximum benefits. Please contact your insurance company with any questions you may have regarding your coverage.

Please Initial:

3. *I request that payment of authorized Medicare and/or other insurance company benefits be made to Comprehensive Urology Medical Group on my behalf for any services furnished to me by CUMG. I authorize release of any information needed to determine those benefits to pay for related services.

Please Initial:

4. PPOs. Please check your insurance provider booklet to see if we are members of your specific plan. If we are not, you will be responsible for the balance not covered by your insurance plan, regardless of the insurance company's determination of usual and customary rates. If we are a participating provider, you will only be responsible for non-covered services, co-payments, co-insurance and deductibles.

Please Initial:

5. HMOs. We DO NOT accept any HMO plans. If you have an HMO policy regardless of the payor (i.e., Medicare, HealthNet, etc.) you will be considered a cash patient in the practice and payment at the time of the service is expected.

Please Initial:

6. Medicare. Our medical group accepts Medicare assignment; which means that you will be responsible for the co-insurance and deductibles, and the difference between what we charge and what Medicare approves will be written-off. In the event that you have a secondary carrier, you will only be responsible for the deductible if your secondary carrier does not pay the Medicare deductible. Recent Federal Legislation has made it illegal for physicians to routinely write off co-insurances and deductibles.

*Patients who have enrolled in any Medi-Cal plan as their secondary insurance will be responsible for the 20% co-insurance/share of cost & deductible (if applicable).

Please Initial:

7. Advance Beneficiary Notice or Waiver of Liability (Non-Covered Services). Medicare or your insurance (including Medi-Cal) may not pay for all your healthcare services. They may pay only for services they deem "covered services". The fact that they will not pay for a particular service does not mean that it is not medically necessary. You will be informed of how much these services may cost and will be asked to sign the waiver of liability forms.

Please Initial:

Patient Questionnaire(Male)
Page - 11

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Patient Name:

Date of Birth:


8. Insurance Verification. Upon completion of verification of your insurance if it is deemed that your benefits are ones which we are not a participating provider, you will be financially responsible for all services provided to you.

Please Initial:

9. Claim submission. We cannot bill your insurance unless you bring in all insurance information. We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Your insurance benefit is a contract between you and your insurance company. We are not party to that contract.

Please Initial:

10. Insurance Cards. Photocopies of the front and back of all insurance cards will be obtained at the time of the visit. If this information changes at any time you are responsible for providing us with the updated information. If we do not receive your complete insurance information, your account will be assigned a cash status, and payment in full will be required at the time of the visit.

Please Initial:

11. Authorization to release information. CUMG physicians and staff may give out written or verbal information concerning my medical records to any insurance carrier or agent that is authorized to have access to and make copies of my medical records.

Please Initial:

12. Self-Pay/Balance After Insurance Payment. Self-pay patients are required to pay 100% fee for service at the time of the visit. In addition, once the insurance company has paid their contractual portion of the bill, the balance is the patient's responsibility.

Please Initial:

13. Non-payment. If your account is over 60 days past due, you will receive a letter stating you have 30 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated. If a balance remains unpaid, we may refer your account to a collection agency. Should the account be referred to an attorney or collection agency, the undersigned agrees to pay the actual attorney's fees and collection expenses. All delinquent accounts shall bear interest at the legal rate.

Please Initial:

14. Missed appointments. It is important to give us at least 24 hours notice if you will not be able to make an appointment. You will be charged if cancellation does not occur within 24 hours (weekday) of your appointment. Established patient office visits $65.00/ Special Procedures $200.00 (UD, Cysto, PNS or PFR). All CT scans will be charged at a rate of $250.00 if not given a 24 hour notice. Please note that bonafide emergencies may be exempt from this policy.

Please Initial:

15. Special letters and Healthcare related form completion (i.e., DMV, disability, life insurance & jury duty). Any requests for a letter describing any medical conditions and/or treatments will be charged at a rate of $40.00.

Please Initial:

16. Copy of medical records, CD copies. Any request for copies of medical records is a charge of $40 and CD copies will be charged $25 each (request will be completed within 5 to 7 business days from request). Rush request will be charged an additional fee (to be determined by office based on number of pages in chart - expedited within 48 hours of request)

Please Initial:

Patient Questionnaire(Male)
Page - 12

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Patient Name:

Date of Birth:


17. Submission of authorizations and/or appeals for medications and/or services exceeding the normal scope of care. Should your insurance require an authorization for medication and/or services due to special circumstances outside the range of normal expectation a charge of $55.00 will be incurred. This charge is applied due to the amount of time that is required to expedite your medication and/or services to obtain the best results for your medical care. Please note that this request for authorization does not guarantee that your insurance will approve the medication/service being requested.

Please Initial:

18. Special Service(s). There will be particular moments in which a phone consultation and/or telemedicine will be completed versus an in-office visit. These services are not covered by insurance and are defined as discussions that exceed the "normal" conversations following laboratory services and/or ancillary services.

Please Initial:

ACKNOWLEDGEMENT OF RECEIPT OFCOMPREHENSIVE UROLOGY MEDICAL GROUP (CUMG) NOTICE OF FINANCIAL POLICIES

By signing this document, I acknowledge that I understand and agree with CUMG's Financial Policies

Name *(printed):


Signature** (Your Name is Your Electronic Signature)


Date*

Patient Questionnaire(Male)
Page - 13

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A. Notifier: Comprehensive Urology Medical

B. Patient Name:*:


Advance Beneficiary Notice of Noncoverage (ABN)

NOTE: If your insurance doesn't pay for D. Phone and/or on-line Services below, you may have to pay. Your insurance does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect yourinsurance may not pay for the D. Phone and/or on-line services below.

This agreement provides the availability for telephone appointments with our providers without having to come to the office to discuss things that do not require a visit to the office.

D. Phone and/or On-Line Services E. Reason Blue Shield Of California May Not Pay: F. Estimated Cost

99441 - Phone conversation w/physician 5 to 10 minutes of medical discussion

Non-Covered Service

99441 - $55

99442 - Phone conversation w/physician 11 to 20 minutes of medical discussion

 

99442 - $65.00

99442 - Phone conversation w/physician 11 to 20 minutes of medical discussion

 

99442 - $65.00

99443 - Phone conversation w/physician 21 to 30 minutes of medical discussion

 

99443 - $85.00

98966 - Phone conversation w/physician extender (nurse, NP or PA) 5 to 10 minutes of medical discussion

 

98966 - $50.00

98967 - Phone conversation w/physician extender (nurse, NP or PA) 11 to 20 minutes of medical discussion

 

98967 - $60.00

98968 - Phone conversation w/physician extender (nurse, NP or PA) 21 to 30 minutes of medical discussion

 

98968 - $80.00

99444 - Email or some other on-line services to discuss a medical problem w/a physician

 

99444 - $50.00

98969 - Email or some other on-line services to discuss a medical problem w/a physician extender

 

98969 - $40.00

WHAT YOU NEED TO DO NOW:

  • Read this notice, so you can make an informed decision about your care.
  • Ask us any questions that you may have after you finish reading.
  • Choose an option below about whether to receive the D. Phone and/or on-line services listed above.

Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but your insurance cannot require us to do this.

G. Options: Check only one box. We cannot choose a box for you.

OPTION 1. I want the D. phone and/or on-line services listed above. You may ask to be paid now, but I also want my insurance billed for an official decision on payment, which is sent to me on an Explanation of Benefits (EOB). I understand that if my insurance doesn't pay, I am responsible for payment, but I can appeal to my insurance by following the directions on the EOB. If my insurance does pay, you will refund any payments I made to you, less co-pays or deductibles.

OPTION 2. I want the D. phone and/or on-line services listed above, but do not bill my insurance. You may ask to be paid now as I am responsible for payment. I cannot appeal if my insurance is not billed.

Patient Questionnaire(Male)
Page - 14

OPTION 3. I don't want the D. phone and/or on-line services listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if my insurance would pay.

H. Additional Information:

Signing below means that you have received and understand this notice. You also receive a copy.


I. Signature:* (Your Name is Your Electronic Signature)

J. Date:*

Patient Questionnaire(Male)
Page - 15

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RISK ASSESSMENT FOR CARDIOVASCULAR WELLNESS

Patient Name Provider:

Date Of Birth:

1. Do you have erectile dysfunction (if applicable)*

Yes    No

2. Do you experience urinary dysfunction (such as incontinence, urgency, frequency, nocturnal enuresis, etc.)

Yes    No

3. Do you frequently experience pelvic pain?

Yes    No

4. Do you have chronic kidney disease?

Yes    No

5. Have you been diagnosed with low testosterone, a thyroid or hormonal disorder?

Yes    No

6. Do you have sleep apnea?

Yes    No

7. Do you have diabetes?

Yes    No

8. Do you have heart disease?

Yes    No

9. Do you smoke or have a history of smoking?

Yes    No

10. Do you ever have pain or numbness in your fingers, hands, toes or feet or do they ever feel cold?

Yes    No

11. Do you ever get pain in your legs when you walk, have trouble walking, or have an unsteady gait?

Yes    No

12. Do you experience excessive sweating (hyperhidrosis)?

Yes    No

13. Do you have high cholesterol?

Yes    No

14. Do you experience digestive dysfunction (such as abdominal distention, pain, constipation, loss of voluntary bowel control, GERD, IBS, etc.)?

Yes    No

15. Do you frequently experience lightheadedness/dizziness?

Yes    No

16. Do you have high or low blood pressure?

Yes    No

If the patient answers yes to the following, DO NOT PERFORM SUDOMOTOR:

Does patient have pacemaker, defibrillatro?

Yes    No

Cardiac stents and/or hip replacement in past 3 months?

Yes    No

If the patient answers yes to the following, DO NOT PERFORM ANS:

Has the patient had Laser Retinopathy Surgery in past 3 months?

Yes    No

Has the patient been told they have an Atrioventricular(AV)block?

Yes    No

Is the patient pregnant?

Yes    No

Patient Name:*

Signature*


(Your Name is Your Electronic Signature)

Date:

Patient Questionnaire(Male)
Page - 16

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SLEEP DISORDER ASSESSMENT

Your physician is requesting that you complete this Sleep Assessment Form.

This form determines the need for you to have a sleep test, which will evaluate if you have a sleep disorder. Sleep Disorders negatively affect your cardiovascular health and well being, but can be effectively treated.

Date:

DOB:

Name:

Physician Name:

Part 1.

1. Have you ever been told you have Congestive Heart Failure?

Yes    No

2. Have you ever been told you have Coronary Artery Disease?

Yes    No

3. Have you ever had a stroke?

Yes    No

4. Do you take medications for high blood pressure?

Yes    No

5. Have you ever experienced irregular heart rhythms?

Yes    No

6. Have you ever been told that you stop breathing at night?

Yes    No

7. Do you have diabetes?

Yes    No

Part 2.

1. Have you been told that you snore?

Yes    No

2. Do you awaken from sleep with chest pain or shortness of breath?

Yes    No

3. Does your family have a history of premature death in sleep?

Yes    No

4. Is your neck size larger that 15.5 inches (female) or 17.0 inches (male)?

Yes    No

5. Have you ever been diagnosed with Obstructive Sleep Apnea?

Yes    No

6. Are you currently being treated for sleep apnea?

Yes    No

6a. If yes, are you using your apparatus every night?

Yes    No

Epworth Sleepiness Scale How likely are you to doze off while doing the following activities? Please use the following scale:

0 = never, 1 = slight, 2 = moderate, 3 = high. Circle one of the following numbers

Part 3.

1. Being a passenger in a motor vehicle for an hour or more

0

1

2

3

2. Sitting and talking to someone

0

1

2

3

3. Sitting and reading

0

1

2

3

4. Watching TV

0

1

2

3

5. Sitting inactive in a public place

0

1

2

3

6. Lying down to rest in the afternoon

0

1

2

3

7. Sitting quietly after lunch without alcohol

0

1

2

3

8. In a car, while stopped for a few minutes in traffic

0

1

2

3

Total Score:

Scoring Methodology: One "Yes" in Part 1 and one "Yes" in Part 2 order the sleep study or Part 3 score greater than 8 order sleep study

Physician Signature *


(Your Name is Your Electronic Signature)

Date:

Patient Questionnaire(Male)
Page - 17

THIS IS AN ONLINE FORM. DO NOT PRINT