HFH-74-0457-0607 sleep apnea encounter form.qxp

HENRY FORD HOSPITALDATESLEEP APNEA OTOLARYNGOGLOGYENCOUNTER FORM❑ MAIN ❑ FAIRLANE ❑ LAKESIDE❑ WEST BLOOMFIELD ❑ OTHER ____________________MRNNAMEAGE:_____________SEX:_____________SEEN WITH:________________________________________________________DR: ______________________________REFERING PHYSICIAN:ADDRESS:___________________________________________________________________________________________________HFH PHYSICIAN? ❑ YES ❑ NOCHIEF COMPLAINT:Smoking History: NO YES,____________________ Alcohol History: NO YES,_____________________SAMPLE1.) Height ___________________ 7.) Medical history and past surgeries _________________2.) Weight___________________ ________________________________________________3.) Age _____________________ 8.) Time to bed____________________________________4.) Blood Pressure____________ 9.) Wake up time __________________________________5.) Heart Rate________________ 10.) Neck circumference ____________________________6.) Medications_______________ 11.) BMI_________________________________________GENERAL HEALTH: Good Other__________________________________________________________ALLERGY: None Other_________________________MEDICINES: None OtherADDITIONAL HISTORY1.) Previous sleep study done? When? Where? RDI_________Desat_________Cardiac__________2.) Do you or have you used CPAP? 3.) Do you fall asleep at work or when you do not want to?4.) Do you fall asleep while driving? 5.) If female, post menopausal? Hormone replacement?PHYSICAL EXAMNOSE: NECK: ORAL CAVITY:FORM #: HFH-74-0457-0607(FRONT)

MALAMPATTIClass I = visualization of the soft palate, fauces, uvula, anterior and posterior pillars.Class II = visualization of the soft palate, fauces and uvula.Class III = visualization of the soft palate and the base of the uvula.Class IV = soft palate is not visible at all.ESS QUESTIONNAIRESAMPLEHow likely are you to doze off or fall asleep in the following situations, in contrast to feeling justtired? This refers to your usual way of life in recent times. Even if you have not done some ofthese things recently try to work out how they would have affected you. Use the following scaleto choose the most appropriate number for each situation:0 = would never dose1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozingChance of Dozing1. Sitting and reading................................................................................. ________2. Watching T. V.......................................................................................... ________3. Sitting inactive in a public place (e.g. a theatre or meeting).................. ________4. A passenger in a car for an hour without a break ................................. ________5. Lying down to rest in the afternoon when circumstances permit........... ________6. Sitting and talking to someone............................................................... ________7. Sitting quietly after lunch without alcohol............................................... ________8. In a car while stopped for a few minutes in traffic................................ ________Total ________FORM #: HFH-74-0457-0607(BACK)