PSG Form

Malvern Sleep Clinic

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Page 1: Patient Demographics & Intake Information Context

Last Name *

First Name *

Middle Name

Date of Birth (D/M/YY) *

Gender

Health Card No.

Version Code

Home Phone No.

Other Phone No.

Occupation

Patient Address

Referring Physician (The doctor who sent you for this test)

Family Physician

Medical Alerts: List any medical condition you have (Diabetes, Heart Problems)

Allergies and Reactions

Food

Drug

Latex

Other

No Known allergies

HAVE YOU EVER HAD A SLEEP STUDY EITHER AT THIS OR ANY ONTARIO CLINIC?

IF YES, please specify the Month/Year/location of your last sleep study:

Pages 2-4: Sleep Disorder Screening

Section 3 Custom Time and Schedule Profiles:

I fall asleep approximately at:

I get up at:

Take day naps?

How long:

Clinical Screening Metric Symptom Question	Yes	No
SNORING
Do you snore?
I have been told that I am a loud snorer.
I snore more loudly when I sleep on my back.
OBSTRUCTIVE SLEEP APNEA AND DAYTIME SLEEPINESS
I have been told that I sometimes stop breathing during sleep.
I sometimes wake up short of breath or gasping for air.
I feel that I lack energy; I feel tired and/or un-refreshed.
I frequently feel sleepy during the day.
Daytime sleepiness interferes with my job.
Daytime sleepiness interferes with my enjoyment of life.
I have trouble remembering things.
I have difficulty concentrating at work.
People tell me that I am often cranky or irritable.
I sweat excessively during the night.
I wake up in the morning with a headache.
My mouth is dry when I wake up in the morning.
I am overweight.
I have been experiencing impotence.
SLEEP HYGIENE AND SLEEP SCHEDULE DISORDERS
I have regular sleeping hours.
My job involves shift work or working unusual hours.
I don't have time to get the sleep I need.
INSOMNIA, DEPRESSION, ANXIETY
I have difficulty falling asleep at night.
It takes me more than 30 min to fall asleep.
I tend to worry about things and have trouble relaxing.
Thoughts racing through my mind often prevent me from falling asleep.
I wake up frequently during the night.
If I wake up at night, I have trouble falling back to sleep.
I regularly take something in the evening to help me sleep.
I suffer from pain during the night.
I suffer from depression.
I suffer from chronic anxiety.
I take tranquilizers or anti-depressants.
RESTLESS LEGS AND PERIODIC LEG MOVEMENTS
Sometimes I cannot keep my legs still.
I have a crawling sensation in my legs. The legs feel restless, numb, hot or cold. I have the need to move them.
I have been told that my arms or legs kick or jerk during sleep.
I am restless sleeper.
I have iron deficiency.
NARCOLEPSY
I have experienced unexplained weakness somewhere in my body.
I have felt weakness in my body when I laugh or I am upset.
Sometimes just as I am falling asleep or as I am waking up, I feel that my muscles are 'paralyzed' for a few minutes.
I have vivid dreams just as I am falling asleep or waking up.
I have vivid dreams during naps.
Sometimes I see things that are not really there.
There are times when I have an irresistible urge to sleep.
I feel more energetic after taking a nap.
PARASOMNIA
I have a history of sleep talking.
I have history of sleep walking.
I have gone to the kitchen and eaten some food without waking up.
I suffer from nightmares.
I 'act out' my dreams and have injured myself or others.
ACID REFLUX
I have heartburn or an acid taste in my mouth during the night.
I sometimes wake up at night coughing or wheezing.

Social Habits

Alcohol Use

Caffeine Intake (Coffee, Tea, Cola)

My last cup/can today was at

I smoke cigarettes

Other Social Habits Context

I SUFFER FROM: (Co-morbidities Checklist)

Diabetes

High Blood Pressure

History Of Stroke

Seizures

Asthma

Other Lung Disease

Heart Disease

Parkinsons Disease

Other disease (Please explain):

Page 7: Pre-Sleep Questionnaire Assessment

1. What time did you get up today?

2. How much sleep did you get last night?

3. Was last night a normal night?

If no to normal night, please explain:

4. Has today been an unusual day?

If yes to unusual day, please explain:

5. Did you fall asleep or take a nap today?

If yes, what time?

And for how long?

6. Did you drink any alcohol?

If yes, when?

And how much?

7. Indicate how many cups you had today of the following:

Coffee

Cola

Tea

Decaf coffee/tea

Chocolate drinks

8. At what time did you drink your last caffeinated beverage?

9. Do you smoke?

10. Do you feel sleepy while driving?

11. Please list any medications (prescriptions, over-the-counter or herbal) that you have or will take today:

Page 8: The Epworth Sleepiness Scale (ESS Matrix)

0 = would NEVER doze | 1 = SLIGHT chance of dozing | 2 = MODERATE chance of dozing | 3 = HIGH chance of dozing

Situation Framework Description	0	1	2	3
1. Sitting and Reading
2. Watching TV
3. Sitting inactive in a public place (e.g. Theatre or meeting)
4. As a passenger in a car for an hour without a break
5. Lying down to rest in the afternoon
6. Sitting and talking to someone
7. Sitting quietly after lunch without alcohol
8. In a car, while stopped for a few minutes in the traffic

EPWORTH AGGREGATE TOTAL: 0 / 24

Page 9: Consent Form (Adult Validation)

I agree to participate in the sleep study conducted by the Etobicoke-Brampton Sleep Clinic.
In the event of significant symptoms that deem the need for a video recording during the overnight sleep study, I give full consent to the recording itself and any access to the recording by relevant medical staff and related clinic health care professionals to aid in diagnosis, research and/or training.
I understand and allow the sleep specialist and the technologist of Etobicoke-Brampton Sleep Clinic to perform a diagnostic sleep study, therapeutic (CPAP) sleep study, Split sleep study and BiPAP study if it is needed for the diagnosis and treatment of any sleep disorder.
I understand the CPAP machine policy of Etobicoke-Brampton Sleep Clinic. The names of local preferred vendors are provided. In addition you may choose from any ADP approved CPAP Vendor in Ontario.

Date *

Please Print Your Name *

Signature Acknowledgment Option *

I Digitally Sign and Agree

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