<p> PALOS SLEEP CENTER PALOS PULMONARY & INTENSIVE CARE</p><p>Date of Study: ______Arrive at: ______P.M. Depart at 5:30 AM (Note: Sleep technicians leave the premises at 6 AM)</p><p> Please notify the Palos Sleep Center staff in advance if you require any special assistance / accommodations (wheelchair, help using the restroom, hearing interpreter, etc.) so that the appropriate arrangements can be made.</p><p>BEFORE YOU ARRIVE AT THE SLEEP CENTER:  Do NOT drink caffeinated products after 12PM on the day of your test.  Do NOT use lotions, oils, hair sprays or powders on your scalp or skin.  Do SHAVE if you have facial hair  Do bring your identification and insurance  Do bring a comfortable pair of pajamas or shorts (no sweats or silk pj’s)  Do bring any medications you take at night  Do bring your completed sleep paperwork packet  Do NOT BRING any valuables with you to the sleep center</p><p>WHEN YOU ARRIVE AT THE SLEEP CENTER:  Please arrive at your scheduled time unless other arrangements were made in advance. There are no personnel in the sleep center prior to 8:30 PM.  You will have ample time to ask questions  There are forms to complete and the technician will review your health history to assist our Specialist in your diagnosis  There may be a waiting period before the technician prepares you for testing and during this time you may read or watch T.V. until hookup. T.V. AND LIGHTS OUT IS PROMPTLY AT 11:00PM  Please turn off cell phones and watch alarms</p><p>WHAT WILL HAPPEN DURING TESTING?  Approximately two dozen electrodes, belts and various sensors will be applied to your head and body using paste adhesive and tape. The electrodes and sensor monitor your brain waves, muscle, eye movements, breathing, snoring, heart rate and level of oxygen. None of these sensors are painful.</p><p>13303 S. RIDGELAND AVE., UNIT C PALOS HEIGHTS, IL 60463 PHONE: 708.293.8800 FAX: 708.293.8811 1 updated 2/22/13 PALOS SLEEP CENTER PALOS PULMONARY & INTENSIVE CARE</p><p> While you are asleep, the technician will be monitoring your sleep throughout the night.</p><p> If you are scheduled for a CPAP test (Continuous Positive Airway Pressure) you can expect a mask that fits over your nose and a machine that uses room air. </p><p>WHAT IF I NEED TO USE THE RESTROOM DURING THE NIGHT? All you have to do is tell the technician that you need to use the restroom. The technician will hear you through the microphone, respond that he/she is coming and enter the room to disconnect a couple of cables so that you can get up and use the restroom. This only takes a moment. </p><p>HOW LONG BEFORE I RECEIVE RESULTS FROM MY SLEEP STUDY? It will take approximately 7-10 working days for the test results to be read and sent to your physician. You will be contacted by our office if you need further testing or CPAP/BIPAP set-up. The technician cannot provide you with any information about your sleep study. </p><p>IS MY STUDY COVERED BY MY INSURANCE? Sleep studies are covered under most insurance plans, although deductibles and percentages of coverage vary. Our office will verify if prior authorization is needed and that sleep studies are ‘covered’ by your plan. Your insurance will be billed directly for these tests. Details regarding coverage should be directed to your insurance company.</p><p>WHAT ABOUT CANCELLING A STUDY? If you need to cancel your appointment, you must give the sleep center a 24 HOUR notice. A $250 fee will be charged for ‘no shows’ or late cancellations without a 24 HOUR notification. This fee is not covered by Medicare or commercial insurance. To reschedule your study please call (708) 293-8800. **If the office is closed, please follow the prompts to leave an emergency message for Dr. Heniff. **</p><p>13303 S. RIDGELAND AVE., UNIT C PALOS HEIGHTS, IL 60463 PHONE: 708.293.8800 FAX: 708.293.8811 2 updated 2/22/13 PALOS SLEEP CENTER PALOS PULMONARY & INTENSIVE CARE</p><p>SLEEP LAB QUESTIONNAIRE</p><p>Today’s date ______</p><p>Last name: ______First name: ______MI: _____</p><p>Date of birth: ______Height: ______Weight: ______</p><p>Describe your sleep problem in your own words: ______</p><p>______</p><p>______</p><p>______</p><p>What time do you usually go to bed on weekdays? ______Weekends? ______</p><p>How long does it usually take you to fall asleep? ______</p><p>What time do you usually wake up on weekdays? ______Weekends? ______</p><p>Do you usually feel rested upon awakening in the morning? Yes No</p><p>Is your sleep often restless or disturbed? Yes No</p><p>Do you have difficulty falling asleep or staying asleep? Yes No</p><p>Do you suffer with daytime sleepiness or fatigue? Yes No</p><p>Do any of your blood relatives have sleep problems? If yes, please describe:</p><p>______</p><p>______</p><p>13303 S. RIDGELAND AVE., UNIT C PALOS HEIGHTS, IL 60463 PHONE: 708.293.8800 FAX: 708.293.8811 3 updated 2/22/13 PALOS SLEEP CENTER PALOS PULMONARY & INTENSIVE CARE</p><p>Has your weight changed over the past 5 years? If so, how? ______</p><p>Do you drink alcohol? Describe when and how much: ______Last name: ______First name: ______</p><p>Do you smoke cigarettes? How many per day? ______</p><p>Do you use any recreational drugs? Yes No</p><p>List any allergies (medication or environmental): ______</p><p>______</p><p>List all current medical illnesses and conditions: ______</p><p>______</p><p>______</p><p>List all current medications: ______</p><p>______</p><p>______</p><p>Do you snore? Yes No</p><p>Do you awaken from sleep choking or gasping for air? Yes No</p><p>Do you awaken from sleep short of breath? Yes No</p><p>Has anyone told you that you stop breathing during your sleep? Yes No</p><p>Do you have headaches when you awaken in the morning? Yes No</p><p>Do you ever awaken from sleep with your heart pounding? Yes No</p><p>Do you awaken from sleep with heartburn? Yes No</p><p>Do you awaken from sleep with a dry mouth or sore throat? Yes No</p><p>13303 S. RIDGELAND AVE., UNIT C PALOS HEIGHTS, IL 60463 PHONE: 708.293.8800 FAX: 708.293.8811 4 updated 2/22/13 PALOS SLEEP CENTER PALOS PULMONARY & INTENSIVE CARE</p><p>Do you ever become weak or fall asleep suddenly when laughing, crying, or if you are suddenly startled? Yes No Last name: ______First name: ______</p><p>When falling asleep or awakening, do you ever hear or see things that you know are not real? Yes No</p><p>Do you ever feel paralyzed (unable to move or talk) when falling asleep or awakening? Yes No</p><p>Do you ever physically act out your dreams? Yes No</p><p>Do you sleepwalk? Yes No</p><p>Do you grind or clench you teeth during sleep? Yes No</p><p>Do you ever eat or drink at night without being aware of doing so? Yes No</p><p>Do you have episodes of bedwetting? Yes No</p><p>Do you have frequent nightmares? Yes No</p><p>Given the following situations, how likely are you to fall asleep? (Use the rating scale to choose the best answer)?</p><p>0 = Would never fall asleep 1 = Slight chance of falling asleep 2 = Moderate chance of falling asleep 3 = High chance of falling asleep</p><p>Sitting and reading? ______Watching television? ______Sitting inactive in a public place (i.e. a theater or meeting)? ______As a passenger in a 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 lunch without alcohol? ______While driving a car, stopped for a few minutes in traffic? ______</p><p>TOTAL ______13303 S. RIDGELAND AVE., UNIT C PALOS HEIGHTS, IL 60463 PHONE: 708.293.8800 FAX: 708.293.8811 5 updated 2/22/13 PALOS SLEEP CENTER PALOS PULMONARY & INTENSIVE CARE</p><p>13303 S. RIDGELAND AVE., UNIT C PALOS HEIGHTS, IL 60463 PHONE: 708.293.8800 FAX: 708.293.8811 6 updated 2/22/13</p>