Medical Record-Supplemental Medical Data printable pdf download

MEDICAL RECORD SUPPLEMENTAL MEDICAL DATA

For use of this form, see AR 40-66; the proponent agency is the Office of the Surgeon General

REPORT TITLE:

SLEEP HISTORY QUESTIONNAIRE

OTSG APPROVED

(Date)

Apr

Age _ _ DaB

MalelFemale (circle) Height

Weight_ _

Home Address:

Telephone:

Home:

Work:

Cell:

Circle One:

Active Duty

Retired

Civilian

Rank:

MaS

Unit Phone #

Are you deploying in the next 12 months?

Yes No

If yes, what month/yr

Are you retiring in the next 12 months?

Yes No

If yes, what month/yr

Are you undergoing an MEB?

Yes No

Are you PCSing?

Yes No

If yes, what month/yr

Are you ETSing?

Yes No

If yes, what month/yr

Are you going on leave?

Yes No

If yes, what month/yr

Are you going on TOY?

Yes No

If yes, what month/yr

What problems are you having with your sleep?

Have you had a sleeping problem diagnosed in the past?

Yes No

If yes, describe:

EXCESSIVE SLEEPINESS:

Do you feel excessively sleepy in the daytime?

Yes No

If yes, how long? _ _months/years

Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to

your usual way oflife in recent times. Even if you have not done some of these things recently, try to work out how

they would have affected you. 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=HiJ!h chance of dozing

Sitting and reading

Watching TV

Sitting, inactive in a public place

Riding as a passenger in the 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 a lunch without alcohol

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

Total

(Continue on reverse)

PREPARED BY (Signature

Title)

DEPARTMENT/SERVICE/CLINIC

DATE (YYYYMMDD)

PATIENT'S IDENTIFICATION (For typed or written entries

D HISTORYIPHYSICAL

D FLOWCHART

give: Name,-last, first, middle; grade; date; hospital or medical

facility)

D OTHER EXAMINATION

D OTHER (Specify)

OR EVALUATION

D DIAGNOSTIC STUDIES

DTREATMENT

USPA

Vl.OO

EDITION OF MAY 78 IS OBSOLETE CRDAMC OP 501

1 May 10

DA FORM 4700, FEB 2003

Medical Record-Supplemental Medical Data

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