Medical Record-Supplemental Medical Data Page 3
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1
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4REPORT TITLE:
Sleep Study Questionnaire (Continued)
PARASOMNIAS/ OTHER:
Did you have a sleep problem as a child?
If yes, describe
Do you currently have nightmares or night terrors?
Do you grind or clench your teeth at night?
Did you frequently wet the bed as a child?
Have you ever wet the bed as an adult?
Have you ever been told that you walk in your sleep?
Have you recently walked in your sleep?
Have you ever been told you make unusual movements such a
swinging arms about, acting out dreams, etc. during
Have you ever felt sudden muscle weakness when you laughe
Have you ever had a sleep related driving accident or a near m
MEDICAL AND SURGICAL HISTORY:
Mark any of the following disorders that you have been
diaWlosed with (active problem or cured)
.
d or got angry?
s talking,
sleep?
iss?
Yes
No
Insomnia
Narcolepsy
Restless Legs Syndrome
COPD
Asthma
Coronary Artery Disease
Congestive Heart Failure
Atrial Fibrillation
Diabetes Mellitus
Hypertension
High Cholesterol
Reflux Disease (GERD)
Renal Failure
Stroke
Depression
Anxiety
ntries
edical
Post Traumatic Stress Disorder
(PTSD)
PREPARED BY (Signature
&
Title)
PATIENT'S IDENTIFICATION (For typed or written e
give: Name,-last, fIrst, middle; grade; date; hospital or m
facility)
MEDICAL RECORD SUPPLEMENTAL MEDICAL DATA
For use of this form, see AR 40-66; the proponent agency is the Office of the Surgeon General
OTSG APPROVED
(Date)
1
Apr
10
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Have you ever been unable to move your body just as you were falling asleep or waking up?
Yes No
Have you ever had exceptionally vivid dreams just as you were falling asleep or waking up?
Yes No
Yes No
FAMILY HISTORY:
Mark any of the following disorders that an
immediate family member has been diagnosed
with (active problem or cured)
Yes
Obstructive
Sleep Apnea
Narcolepsy
Restless Leg
Syndrome
Coronary
Artery
Disease
Hypertension
No
(Continue on reverse)
I
DEPARTMENT/SERVICE/CLINIC
I
DATE (YYYYMMDD)
o
HISTORYIPHYSICAL
o
FLOWCHART
o
OTHER EXAMINATION
o
OTHER (Specify)
OR EVALUATION
o
DIAGNOSTIC STUDIES
o
TREATMENT
DA FORM 4700, FEB 2003
EDITION OF MAY 78 IS OBSOLETE CRDAMC OP 501
USPA
Vl.OO
1 May 10 (cont)
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