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Sleep Disorder Evaluation Template | PDF | Sleep Disorder | Sleep Apnea
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Sleep Disorder Evaluation Template

The Sleep Disorder evaluation MedicalTemplate is suitable for any physician or health care provider that evaluates patients with sleep disorders such as sleep apnea, narcolepsy, or restless leg syndrome. Sleep disorders include obstructive sleep apnea, narcolepsy, restless leg syndrome, insomnia, night terrors and others. The National Center on Sleep Disorders Research (NCSDR) estimates that 42 million Americans suffer from a chronic sleep disorder. Sleep disorders are associated with chronic sleep deprivation, elevated blood pressure, cardiovascular disease, pulmonary hypertension, cognitive dysfunction, erectile dysfunction, chronic fatigue, and other medical conditions that result in $15.9 billion in health care costs annually. Sleep disorders can have a detrimental influence in the workplace and school performance, and people who are chronically sleep deprived due to sleep disorders are at increased risk of auto accidents. The Sleep Disorder Evaluation MedicalTemplate has prompters for the sleep history, medical history, medication use that affects sleep architecture, drug use history, auto accident history, physical examination, and testing options. This assists physicians in efficiently documenting a thorough history.

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9K views2 pages

Sleep Disorder Evaluation Template

The Sleep Disorder evaluation MedicalTemplate is suitable for any physician or health care provider that evaluates patients with sleep disorders such as sleep apnea, narcolepsy, or restless leg syndrome. Sleep disorders include obstructive sleep apnea, narcolepsy, restless leg syndrome, insomnia, night terrors and others. The National Center on Sleep Disorders Research (NCSDR) estimates that 42 million Americans suffer from a chronic sleep disorder. Sleep disorders are associated with chronic sleep deprivation, elevated blood pressure, cardiovascular disease, pulmonary hypertension, cognitive dysfunction, erectile dysfunction, chronic fatigue, and other medical conditions that result in $15.9 billion in health care costs annually. Sleep disorders can have a detrimental influence in the workplace and school performance, and people who are chronically sleep deprived due to sleep disorders are at increased risk of auto accidents. The Sleep Disorder Evaluation MedicalTemplate has prompters for the sleep history, medical history, medication use that affects sleep architecture, drug use history, auto accident history, physical examination, and testing options. This assists physicians in efficiently documenting a thorough history.

Uploaded by

e-MedTools
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Sleep Disorder Evaluation Patient Name Pt DOB

Date Chief complaint/Reason for consult Referring MD


Start time
Stop time
Medications History of Present Illness ‰Patient is Nonverbal. History obtained from ‰ Family ‰ Medical records
‰Medication list reviewed
‰Medications reconciled with Nursing
Home or Hospital discharge
Information œ46
‰Patient takes antidepressants, benzodiazepines, stimulants, narcotics, anti-seizure medications, alcohol or recreational drugs
Changes as follows ‰Loud snoring or gasping, choking sounds ‰Excessive daytime sleepiness
‰Witnessed apnea ‰Auto accidents in the past 12 months
‰Fatigue despite adequate sleep ‰Sleep walking or eating
‰Vivid dreams ‰Night terrors
Allergies ‰Difficulty falling asleep or staying asleep ‰Leg jerks while sleeping
‰ Allergy List reviewed ‰Hypnogogic or Hynopompic symptoms ‰Restless legs symptoms
‰ No drug allergies ‰Sudden muscle weakness associated with strong emotions ‰Recent weight gain of >10 pounds
‰ No food allergies ‰Estimated number of hours of sleep/night ‰# Caffeinated beverages consumed/day
Social History Review of Systems
‰Never Smoker See HPI WNL
‰Tobacco ____ # Packs X ____ # Yrs ‰‰ Constitutional Fatigue, malaise, fever/chills, weight loss, change in appetite
‰ Quit ‰‰ Eyes Vision changes, New pain, Scotomas
Patient has tried ‰Nicotine replacement ‰‰ ENT/mouth Nose bleeds, dental caries, dental abscesses, jaw pain
‰Buproprion or nortriptyline ‰‰ Resp Dyspnea, Cough, Phlegm, Hemoptysis, Wheeze, Witnessed Apnea
‰Nicotine receptor blockade ‰‰ CV Chest pain, diaphoresis, ankle edema, PND, syncope
Daily, occasional and ex-smokers are more ‰‰ GI Emesis, dysphagia, GERD, abdominal pain, diarrhea, melena
likely to be hazardous drinkers
‰‰ GU Change in urinary habits, hematuria, dysuria
‰Alcohol use
‰‰ Musc Myalgias, recent trauma, bony fractures, arthralgias, joint swelling
______ Drinks per ‰day ‰week
Hazardous drinking ‰‰ Skin/breasts Rashes, new masses or skin lesions, increased sensitivity to sun
NIAAA (National Institute on Alcoholism ‰‰ Neuro Seizures, episodic or chronic muscle weakness
and Alcohol Abuse guidelines) ‰‰ Endo Hair loss, polydipsia
Men > 14 drinks per week OR ‰‰ Heme/lymph Bleeding gums, unusual bruising, swollen lymph nodes
> 4 drinks per day ‰‰ Allergy/Immun Sinus probs, recurrent infections
Women > 7 drinks per week OR
>3 drinks per day ‰‰ Psych Mood changes, agitation, psychosis, delirium, dementia
‰Recreational drug use Occupational History ‰Shift work If yes, describe work schedule
‰Inhalational ‰Injectable ‰Ingestible
‰Drug dependence
‰Narcotics ‰Benzodiazepines
Family Medical History Past Medical History Surgical History
‰ Asthma ‰ Asthma ‰Deviated septum ‰Denies surgical history
‰ Congestive Heart Failure ‰ Cerebral Artery Disease ‰ Head and neck cancer ‰ENT surgeries
‰ COPD ‰ Congestive Heart Failure ‰ Insomnia ‰ Rhinoplasty
‰ Coronary Artery Disease ‰ COPD ‰ Narcolepsy ‰ Jaw surgery
‰Premature Onset
‰ Coronary Artery Disease ‰ Nasal polyps ‰ Polypectomy
‰ Malignancy
‰ Narcolepsy ‰ GERD ‰ Obstructive Sleep Apnea ‰ Uvulopalatopharyngoplasty
‰ Neuromuscular Disease ‰ Hepatic Dysfunction ‰ Radiation to neck or head
‰ Obstructive Sleep Apnea ‰ Hypertension ‰ Restless Legs Syndrome 
‰ Pancreatitis ‰ Neuromuscular weakness ‰ Periodic Leg Movement Disorder
‰ Peripheral Artery Disease ‰ PAH ‰ Swallowing disorder
‰ Renal Dysfunction ‰ Peripheral Artery Disease
‰ Thrombotic disorder ‰ Rheumatoid arthritis
‰ Thyroid Disease ‰ Sarcoidosis
‰ Scleroderma
‰ Seizure Disorder
‰ Thyroid Disease Vaccines ‰Flu ‰Pneumo ‰BCG ‰Tetanus ‰Pertussis ‰Varicella

©MB and RR 2006-2008 Revised 6Feb08 œIndicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures
Sleep Disorder Evaluation Patient Name Pt DOB
Prior Diagnostic Data Exam
‰ ECHO/Stress Test General‰Alert Vitals T P R BP Sats %
‰ Sleep Study ENT ‰Nasal mucosa ‰Dentition ‰Oropharynx Mallampati ‰I ‰II ‰III ‰IV
‰ Full night Neck ‰Normal to palpation ‰Thyroid ‰No JVD
‰ Split night Resp ‰Clear to auscultation ‰Dullness to percussion ‰No respiratory distress

Apnea/Hypopnea Index ___ ‰No chest wall defects ‰Decreased fremitus ‰Bronchial breath sounds
 ‰Absence of intercostal respiratory retractions ‰Egophony (E to A change)
‰ Multiple Sleep Latency Test CV ‰Clear S1 S2 ‰No murmur ‰No gallop ‰No rub ‰Peripheral pulses ‰No peripheral edema

‰Maintenance Wakefulness Test GI ‰No palpable masses ‰Liver and spleen not palpable ‰No hepatojugular reflux
Lymph ‰No lymphadenopathy
Musc ‰Tone ‰Gait
Extrem ‰No clubbing ‰No cyanosis
Skin ‰No rashes, ecchymoses, nodules, ulcers
Neuro ‰Oriented œ58(Pts with Community Acquired Bacterial Pneumonia) ‰Affect
Plan Impression
‰Pneumonia vaccine Epworth Sleepiness Score
‰Influenza vaccine 
 
‰Smoking cessation aids 
‰Labs 


‰12-lead EKG 
‰Echocardiogram 
‰CXR 
‰Inspiratory and Expiratory 
‰CT of Chest 
‰Pulmonary Function Testing 
‰Overnight Polysomnography 
‰MSLT 
‰Maintenance Wakefulness Test 
‰CPAP 
‰BiPAP 
‰Supplemental Oxygen 






Follow Up Signature
cc: 
‰ Patient has completed advanced health care directivesœ47 HCPOA is
Code Status ‰ Patient is a FULL CODE ‰ DO NOT ATTEMPT RESUSCITATION

©MB and RR 2006-2008 Revised 6Feb08 œIndicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures

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