Sleep Intake Form

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Sleep Intake Form
Personal Information
Name: ________________________________________________________
Today’s Date: ____/____/_____
First
Last
Address: ______________________________________________________
Phone (H): __________________
City: __________________________________________________________
Phone (C): __________________
Email: _________________________________________________________ Phone (W): _________________
Date of Birth: ____/____/_______
Age: ____________
Gender:
F
M
Employer: _____________________________________________________
Occupation: ________________
How did you hear about us? Internet:
Referral:__________________
Other: _____________________
In case of emergency, who should be notified? _____________________ Phone: _____________________
Primary Care Physician: __________________________________________ Phone: _____________________
Sleep Physician: ________________________________________________ Phone: _____________________
Sleep Facility: __________________________________________________ Phone: _____________________
Date of Baseline Sleep Study: ____/____/________ CPAP Trial:
Patient Chief Complaint and Patient Expectations
Briefly describe your problem with your sleep as you see it.
What is the nature of assistance you expect or desire?
Notice of Privacy Practices Acknowledgement:
I understand that, under the Health Insurance Portability & Accountability Act of 1996, I have certain
rights to privacy regarding my protected health information. I have received your Notice of Privacy
Practices containing a more complete description of the uses and disclosures of my health information.
I understand that this organization at any time at the address above to obtain a current copy of the
Notice of Privacy Practices.
Patient Name: ____________________________________ Relationship to Patient: ____________________
Patient Signature: _________________________________________________
Date: ____/____/________
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