Follow Up Patient Form

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Johns Hopkins Center for Sleep
Follow Up Patient Form
Leave blank for label
What is the reason you are here today? ________________________________________________________________
_________________________________________________________________________________________________
REVIEW OF SYMPTOMS – Please check all those that apply based on symptoms over the last month.
o Dizziness
o Diarrhea
Pain Rating (now) _______ (0-10)
o Fatigue or tiredness
o Headaches
o Constipation
o Overly sleepy
o Difficulty with
o Stomach problems
o Fever
o Sour taste
memory/concentration
o Chills
o Changes in your mood
o Belching
o Night sweats
o Changes in your behavior
o Reflux
o Hot flashes
o Claustrophobia/Anxiety
o Leg cramps
o Chest pain
o Seasonal allergies
o Joint pains ________ (0-10)
o Swelling in feet
o Nasal congestion
o Back pains ________ (0-10)
o Swelling in legs
o Runny nose
o Rash
o Blood in urine
o Shortness of breath at rest
o Excessive thirst
o Blood in stools
o Shortness of breath with activity
o Weight gain
o Frequent urination
o Cough
o Other ___________________
Epworth: How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This
refers to your usual way of life in recent times. Even if you haven’t done some of the activities recently, think about
how they would have affected you. Use this scale to choose (circle) the most appropriate number for each situation:
1 = slight chance of dozing
3 = high chance of dozing
Sitting and reading
0
1
2
3
Score
Watching TV
0
1
2
3
Sitting inactive in a public place
0
1
2
3
Being a passenger in a motor vehicle for an hour or more
0
1
2
3
__________
Lying down in the afternoon
0
1
2
3
Sitting and talking to someone
0
1
2
3
Sitting quietly after lunch (no alcohol)
0
1
2
3
Stopped for a few minutes in traffic while driving
0
1
2
3
Patient Signature: ____________________________________________________ Date & Time: __________________

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