REV. 09.27.2019

SLEEP CENTER LOCATION 3020 Hamaker Court Suite 401 Fairfax, VA 22031

For appointments: (703) 876-2850 For after-hour emergencies: (703) 876-5645

PLEASE FAX THIS SIGNED FORM TO (571) 308-1158 IN ORDER TO SCHEDULE YOUR SLEEP STUDY. THANK YOU.

SLEEP STUDY GUIDELINES

1. INSURANCE APPROVAL: Please sign and fax this form to (571) 308-1158. Once this form has been received, we will work to obtain approval from your insurance company. This process can take up to 4-6 weeks. Once we have received authorization from your insurance company, we will call you to schedule your sleep study. In some cases, your insurance company may only authorize a home sleep study. We will let you know.

2. SLEEP FORMS: Please complete all the forms in the sleep packet and bring them with you on the night of your sleep study.

3. ARRIVAL/ DEPARTURE: Please arrive at the sleep laboratory between 8:30 and 8:45 PM, and arrange to

leave by 5:30 AM the next morning. You will need to press the after-hours Neurology Center buzzer at the main doors to the building on Hamaker Court to obtain entry for your study.

4. ROOM: A private bedroom with bathroom (no shower) and television will be reserved for you. Please let us

know as early as possible if you must cancel or reschedule your sleep study.

5. WHAT TO BRING: If you wear a hearing aid, please bring that with you. Bring your own toiletries and loose, comfortable clothing to sleep in. If you will be staying for the daytime nap test (Multiple Sleep Latency Test), you may want to bring reading materials and/or your computer to help pass the time between the nap tests. Please also bring something to eat for breakfast and lunch.

6. BEFORE THE TEST: Please take a shower before coming to the sleep center. To help us obtain the most

accurate study, please do not put any type of gel, mousse, or spray into your hair. Also, please do not use any skin lotion, cream, or makeup.

7. MEALS: Please eat your normal dinner before coming to the sleep center. You will be finished with your

sleep study prior to breakfast time. Food and beverages are not kept in the sleep center.

8. NAPS: Try not to take any naps during the day before your test. We want you to be sleepy on the night of your sleep study.

9. ALCOHOL/CAFFEINE: Please refrain from all caffeinated and alcoholic beverages after 3:00 PM on the day of your sleep study.

10. MEDICATIONS: Please bring any medications you usually take at night and in the morning. 11. COLDS AND FLU: If you become sick before your sleep study, please reschedule the sleep study so that an

accurate test can be performed. Please call us as soon as possible to reschedule your test. 12. REGULATION: Smoking, alcohol use, illegal substances, or weapons of any type are strictly prohibited on

the premises.

13. CANCELLATION: Please provide at least 48-hours notice if you need to cancel your sleep study. A $250 fee will be charged if you cancel within 48-hours or do not show up for your sleep study.

14. FOLLOW-UP: Within 7-10 days of completing your sleep study, a staff member will call you by phone to

provide you with the results of your sleep study. You are welcome to obtain a copy of your sleep study report anytime.

If your sleep study shows sleep apnea, you will be referred to do a “treatment” sleep study with CPAP therapy. After completing this study, you will be notified of the results within 7-10 days and be given the option to receive new CPAP equipment at home to treat your sleep apnea. In all cases, please make sure to schedule a follow-up visit with your physician. You may also make an appointment to see our sleep specialist, Dr. Richard Cho. For more information about sleep apnea and CPAP therapy, please look in your packet or go to our website: http://yoursleepcenter.net

I UNDERSTAND THE ABOVE AND HAVE RECEIVED A COPY OF THIS FORM. PRINTED NAME DATE OF BIRTH PATIENT SIGNATURE DATE Primary Phone Number:

Secondary Phone Number:

Sleep Study Information Neurology Center of Fairfax

1) Your NCF physician may order a diagnostic sleep study (polysomnogram) to determine if you have a

sleep disorder.

2) Our billing department will work to obtain insurance approval for your diagnostic sleep study and

then will contact you to schedule the study.

3) The diagnostic sleep study will be performed at the Neurology Center of Fairfax (Suite 401).

4) If your diagnostic sleep study (polysomnogram) is normal, you will receive a letter in the mail. Please

follow up with your NCF physician for further care and management.

5) If your diagnostic sleep study shows sleep apnea, you will be contacted and a second sleep study for

CPAP (continuous positive airway pressure) titration will be ordered. This study will determine the best

pressure setting and mask fit to treat your sleep apnea.

Our billing department will work to obtain insurance approval for your CPAP titration study and then will

contact you to schedule the study.

6) After completing the CPAP titration study, Dr. Richard Cho (board-certified sleep specialist) will

provide an order so that you can receive the appropriate CPAP (Continuous Positive Airway Pressure)

equipment (machine, mask, tubing, etc.).

With your permission, the Neurology Center of Fairfax will submit your order and information to a

reputable durable medical equipment company (DME). This company will provide you with the CPAP

equipment. PLEASE VERIFY THAT YOU HAVE THE PROPER PREAUTHORIZATIONS FROM YOUR

INSURANCE COMPANY AND THAT THE DME COMPANY IS COVERED BY YOUR INSURANCE PLAN.

7) You may return to see your NCF physician before starting CPAP therapy to ask questions about your

diagnosis, sleep study results, and CPAP equipment. This is only if you desire to do so.

You also have the option to schedule a sleep-medicine consultation with Dr. Richard Cho, our board-

certified sleep specialist. This is suggested by your neurologist.

8) As a patient using CPAP therapy, you must follow up with your physician or Dr. Cho on a regular basis

in order to maintain insurance coverage of your CPAP equipment.

Medicare patients must have a face to face visit with their physician with documented sleep

issues/symptoms within 6 months of the order for CPAP equipment.

MEDICARE PATIENTS must be seen by a physician between 31 and 90 days after initiation of CPAP therapy. The home CPAP data report must show the use of CPAP > 4 hours per night on 70% of nights during a consecutive thirty-day period anytime during the first 3 months of initial usage. There also needs to be written documentation in the note that the patient is “using and benefitting from CPAP therapy” (exact wording). Questions about sleep studies should be directed to the Sleep Center at 703-876-0800 ext. 5043. Leave a message and your call will be returned. Questions about sleep equipment (i.e. CPAP machines, mask) should be directed to the Nurse Sleep

Coordinator at 703-876-0800 ext. 1064. Leave a message and your call will be returned.

Rev. 08.29.2017

Original To Patient - Copy To Doctor

Medication List

Please include all prescriptions, vitamins, and over-the-counter medications.

Name: ___________________________ Pharmacy:_______________________

Pharmacy

DOB: __________________________ Phone:__________________________

Pharmacy

Cell Phone:_______________________ Fax: ____________________________

Medication/Allergies:_____________________________________________________________________________

________________________________________________________________________________________________

Medication Dosage Frequency/Time Prescribed By Taken For

COPY PAGE AS NECESSARY

Rev. 07/17/2017

Rev. 12.19.2017

SLEEP HEALTH QUESTIONNAIRE

Patient Name: Date: Present height: ___________ Present weight: ___________ DOB: ________________ 1. Please state in your own words the reason for a sleep evaluation.

2. Have you had a previous sleep evaluation? If so, when and what were the results?

3. Please check any of the following that may affect your sleep: Snoring Morning dry mouth Chest pain Choking sensation Morning headache Sweating at night Shortness of breath Heart racing ---------------------------------------------------------------------------------------------------------------- ------------------------------------------------------ Difficulty falling asleep Worried about not sleeping Waking up before alarm Many awakenings Anxiety/ racing thoughts Sleeping better when away from home Restless sleep Sadness or depression ----------------------------------------------------------------------------------------------------------------------------- ----------------------------------------- Urge to move legs Leg/foot cramps Muscle tension Relief with movement Pain or discomfort Worse at night Creepy-crawly feeling ----------------------------------------------------------------------------------------------------------------------------- ----------------------------------------- Nightmares/ bad dreams Wake up confused Eating at night Wake up in a panic Acting out dreams Wet the bed Wake up screaming Sleep walking Seizure movements Wake up with violence Sleep talking ----------------------------------------------------------------------------------------------------------------------------------------------------- ----------------- Feeling unable to move Daytime sleep attacks Sounds/images when falling asleep or waking up Does your body get weak when you become emotional (i.e. laughter)? ----------------------------------------------------------------------------------------------------------------------------- ----------------------------------------- Noise Room temperature Bed partner/moving Caring for children Other (please describe): ----------------------------------------------------------------------------------------------------------------------------- ----------------------------------------- 4. Have you had a motor vehicle crash (or near-miss) due to daytime sleepiness? If so, how often and/or when did it occur? ______________________________________________________________________________________________________ 5. How much weight have you gained or lost in the past 1 year? How often do you exercise? __________________________ What time of the day?

Rev. 12.19.2017

6. Are these activities you do in the bedroom at night? Please circle the most appropriate answer. Watch TV NEVER LESS THAN ONE NIGHT 2-3 NIGHTS 2-3 NIGHTS MOST EVERY ONCE PER PER MONTH PER MONTH PER WEEK NIGHTS NIGHT MONTH Use a computer NEVER LESS THAN ONE NIGHT 2-3 NIGHTS 2-3 NIGHTS MOST EVERY ONCE PER PER MONTH PER MONTH PER WEEK NIGHTS NIGHT MONTH Work NEVER LESS THAN ONE NIGHT 2-3 NIGHTS 2-3 NIGHTS MOST EVERY ONCE PER PER MONTH PER MONTH PER WEEK NIGHTS NIGHT MONTH Read or study NEVER LESS THAN ONE NIGHT 2-3 NIGHTS 2-3 NIGHTS MOST EVERY ONCE PER PER MONTH PER MONTH PER WEEK NIGHTS NIGHT MONTH Talk on phone NEVER LESS THAN ONE NIGHT 2-3 NIGHTS 2-3 NIGHTS MOST EVERY ONCE PER PER MONTH PER MONTH PER WEEK NIGHTS NIGHT MONTH Listen to radio NEVER LESS THAN ONE NIGHT 2-3 NIGHTS 2-3 NIGHTS MOST EVERY ONCE PER PER MONTH PER MONTH PER WEEK NIGHTS NIGHT MONTH Eat NEVER LESS THAN ONE NIGHT 2-3 NIGHTS 2-3 NIGHTS MOST EVERY ONCE PER PER MONTH PER MONTH PER WEEK NIGHTS NIGHT MONTH 7. SLEEP SCHEDULE

What time do you go to bed?

Do you take any sleep aids? How often?

How long does it take you to fall asleep?

How many times do you wake up during the night?

What time do you wake up in the morning? Do you feel refreshed in the morning?

How often do you take naps?

8. What are your work hours? __________________________ What days do you work? ______________________________

Rev. 12.19.2017

9. HABITS Do you drink caffeinated coffee? yes no If yes, how many cups per day? Do you drink caffeinated tea? yes no If yes, how many cups per day? Do you drink caffeinated soda? yes no If yes, how many cans per day? What time is your last drink? _______ Do you drink wine? yes no If yes, how much per day or week? Do you drink beer? yes no If yes, how much per day or week? Do you drink mixed drinks? yes no If yes, how much per day or week? What time is your last drink? _______ Do you smoke cigarettes? yes no If yes, how many per day? Do you smoke cigars? yes no If yes, how many per day? Do you chew tobacco? yes no If yes, how much per day? What time was your last use? How long have you used tobacco? _________________________ Do you have a history of non-prescription drug use? If so, please list what you have used:

10. How likely are you to doze off or fall asleep in the following situations? Even if you have not done some of these things recently, try to think about what would happen in these situations. Use the following scale to choose the most appropriate number for each situation.

0 = would never doze off 1 = slight chance of dozing off 2 = moderate chance of dozing off 3 = high chance of dozing off

SITUATION

CHANCE OF DOZING

Sitting and reading 0 1 2 3

Watching TV 0 1 2 3

Sitting quietly in a public place (i.e. theatre or meeting) 0 1 2 3

As a passenger in a car for an hour without a break 0 1 2 3

Lying down to rest in the afternoon when able to 0 1 2 3

Sitting and talking to someone 0 1 2 3

Sitting quietly after a lunch without alcohol 0 1 2 3

In a car, while stopped for a few minutes 0 1 2 3

Rev. 12.19.2017

Feelings Survey: Please read each statement carefully and pick out the one that best describes how you have been feeling over the past 2 weeks, including today. Circle only one number (0 through 3) for the statement you have picked. 1 12 0 I do not feel sad. 0 I have not lost interest in other people or activities. 1 I feel sad much of the time. 1 I am less interested in other people or things than before. 2 I am sad all of the time. 2 I have lost most of my interest in other people or things. 3 I am so sad or unhappy that I cannot stand it. 3 It’s hard to get interested in anything. 2 13 0 I am not discouraged about my future. 0 I make decisions about as well as ever. 1 I feel more discouraged about my future than I used to be. 1 I find it more difficult to make decisions than usual. 2 I do not expect things to work out for me. 2 I have much greater difficulty in making decisions than I used to. 3 I feel my future is hopeless and will only get worse. 3 I have trouble making any decisions. 3 14 0 I do not feel like a failure. 0 I do not feel I am worthless. 1 I have failed more than I should have. 1 I don’t consider myself as worthwhile and useful as I used to. 2 As I look back, I see a lot of failures. 2 I feel more worthless as compared to other people. 3 I feel I am a total failure as a person. 3 I feel utterly useless. 4 15 0 I get as much pleasure as I ever did from the things I enjoy. 0 I have as much energy as ever. 1 I don’t enjoy things as much as I used to. 1 I have less energy than I used to have. 2 I get very little pleasure from the things I used to enjoy. 2 I don’t have enough energy to do very much. 3 I can’t get any pleasure from the things I used to enjoy. 3 I don’t have enough energy to do anything 5 16 0 I don’t feel particularly guilty. 0 I have not experienced any change in my sleeping pattern. 1 I feel guilty over many things I have done or should have done. 1a I sleep somewhat more than usual. 2 I feel quite guilty most of the time. 1b I sleep somewhat less than usual. 3 I feel guilty all of the time. 2a I sleep a lot more than usual. 2b I sleep a lot less than usual. 6 3a I sleep most of the day. 0 I don’t feel I am being punished. 3b I wake up 1-2 hours early and can’t get back to sleep. 1 I feel I may be punished. 2 I expect to be punished. 17 3 I feel I am being punished. 0 I am no more irritable than usual. 1 I am more irritable than usual. 7 2 I am much more irritable than usual. 0 I feel the same about myself as ever. 3 I am irritable all the time. 1 I have lost confidence in myself. 2 I am disappointed in myself. 18 3 I dislike myself. 0 I have not experienced any change in my appetite. 1a My appetite is somewhat less than usual. 8 1b My appetite is somewhat greater than usual. 0 I don’t criticize or blame myself more than usual. 2a My appetite is much less than usual. 1 I am more critical of myself than I used to be. 2b My appetite is much greater than usual. 2 I criticize myself for all of my faults. 3a I have no appetite at all. 3 I blame myself for everything bad that happens. 3b I crave food all the time. 9 19 0 I don’t have any thoughts of killing myself. 0 I can concentrate as well as ever. 1 I have thoughts of killing myself, but I would not carry them out. 1 I can’t concentrate as well as usual. 2 I would like to kill myself. 2 It’s very hard to keep my mind on anything for very long. 3 I would kill myself if I had the chance. 3 I find I can’t concentrate on anything. 10 20 0 I don’t cry anymore than I used to. 0 I am no more tired or fatigued than usual. 1 I cry more than I used to. 1 I get more tired or fatigued more easily than usual. 2 I cry over every little thing. 2 I am too tired or fatigued to do a lot of things I used to do. 3 I feel like crying, but I can’t. 3 I am too tired or fatigued to do most of the things I used to do. 11 21 0 I am no more restless or wound up than usual. 0 I have not noticed any recent change in my interest in sex. 1 I feel more restless or wound up than usual. 1 I am less interested in sex than I used to be. 2 I am so restless or agitated that it’s hard to stay still. 2 I am much less interested in sex now. 3 I am so restless or agitated that I have to keep moving or 3 I have lost interest in sex completely. doing something.

Rev. 07/17/2017

DETAILS

CONSENT FOR POLYSOMNOGRAM

A polysomnogram is an overnight sleep study. It records detailed information that shows how your body acts while you sleep. A technologist will attach sensors to your body for the study. These sensors will monitor and record multiple body functions which include:

• Brain wave activity

• Heart rate and rhythm

• Breathing patterns

• Oxygen level

• Eye movements

• Chin movement

The study also may involve other sensors. These sensors send signals to a computer. The sleep center will use this information to prepare a detailed report about your sleep. The doctor who sent you to the sleep center will receive a copy of this report. He or she will then discuss the results with you. Please allow 14 business days for your doctor to receive your sleep report.

RISKS You will sleep in the Sleep Laboratory as you would at home or in a hotel room.

AGREEMENT My signature below indicates that I understand and agree with the following statements:

1. This sleep study may not detect the cause of my sleep problem. 2. A technologist will attach sensors to my body for the study. 3. These sensors may smell bad when they are placed on me. 4. The removal of the sensors in the morning may irritate my skin and cause redness. 5. A video camera will record me as I sleep. A technologist will watch me on a monitor in

the control room. 6. I will be free to roll over and move in bed during the study. 7. I will need to ask for help if I must get out of bed for any reason. 8. The technologist may need to enter the room and wake me if there is a problem. 9. The study may show that I stop breathing many times during the night. If this happens, a

technologist may enter my room to start treatment. This treatment is called positive airway pressure, or PAP. To use this treatment, I will need to wear a mask which covers my nose and possibly my mouth.

10. I understand why I am taking this sleep study. 11. I have discussed the need for the sleep study with my referring doctor. 12. The sleep center staff has explained the sleep study to me. I understand what is going to

happen during the study.

All of my questions have been asked and satisfactorily answered. I agree to the performance of a sleep study with video recording.

Signature (Patient or Guardian) Date

Signature (Witness) Date

REV 07.17.17

PERMISSION TO PHOTOGRAPH AND/OR RECORD AUDIO AND VIDEO

I, _, Patient/Guardian

hereby authorize The Neurology Center of Fairfax/ Sleep Diagnostic and Treatment Center, or their representative, to take photograph(s) and/or record audio and video

of _. Name of Patient

I understand that such photograph(s), audio recording(s) and/or video recordings may be used for clinical or educational purposes, or in the event of legal action. The sleep center and directors of The Neurology Center of Fairfax, Ltd. and its duly appointed representatives are hereby released without recourse from any liability arising from obtaining and using such photograph(s), audio recording(s) and/or video recordings.

The undersigned also hereby transfers and assigns to The Neurology Center of Fairfax/ Sleep Diagnostic and Treatment Center the right to copy the materials in whole or in part. No use of the material for educational purposes will identify me by name.

Check here if you do NOT authorize use for educational purposes.

Signature (patient or guardian) Date

Relationship to Patient if Guardian

Witness Date