Sleep Medicine Intake Form

The Sleep Medicine Intake Form is designed specifically for sleep disorder practices, capturing the detailed sleep history and screening questionnaires that sleep medicine specialists need for accurate diagnosis and treatment planning. This template collects patient demographics alongside a comprehensive sleep assessment covering bedtime and wake time schedules (weekday and weekend), sleep latency, total sleep time, number of awakenings, sleep quality rating, and nap patterns. Validated screening instruments include the Epworth Sleepiness Scale for daytime somnolence and STOP-BANG questionnaire for obstructive sleep apnea risk stratification.

Built for sleep medicine, pulmonary sleep, neurology sleep, and behavioral sleep medicine practices, this form includes sections for insomnia history (onset, perpetuating factors, cognitive and behavioral patterns), sleep apnea symptoms (snoring, witnessed apneas, gasping, morning headaches), restless legs syndrome screening, parasomnias (sleepwalking, night terrors, REM behavior disorder), circadian rhythm concerns (shift work, jet lag, delayed sleep phase), prior sleep study results (PSG, HSAT, MSLT), CPAP or oral appliance use (device type, pressure settings, mask type, compliance, side effects), and a medication review covering hypnotics, melatonin, stimulants, and medications known to affect sleep.

All fields are HIPAA-compliant and optimized for the sleep medicine consultation workflow. The pre-visit questionnaires provide validated screening data that the sleep specialist can review before the appointment, identify the most likely sleep disorder category, and plan the appropriate diagnostic workup. The CPAP compliance section is particularly valuable for patients referred for CPAP troubleshooting or alternative therapy evaluation.