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Referring Provider
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Free text
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Sleep symptoms
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Symptoms free text
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Severity
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Severity Comments
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Duration
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Duration Comments
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Onset / Timing
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Onset Comments
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Context
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Context Comments- The symptoms occur with
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Modifying Factors
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Modifying factors comments
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Progression Comments
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Progression Comments
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Associated Symptoms
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Associated Symptoms Comments
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weight gain
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Rest less legs symptoms
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REM epiphenomena
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REM Epiphenomena
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Neurpsych symptoms
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ENT / Pulmonary symptoms
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Free Text
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Epworth Sleepiness Scale
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Lying down to rest in the afternoon when you can
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Watching TV
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Sitting Inactive in a Public Place
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As a passenger in a car for an hr and no break
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Sitting and Reading
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Playing video games
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Sitting quietly after lunch without alcohol
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Sitting and Talking to Someone
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Total item 1-8
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PAST HISTORY
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No significant PMH/PSH
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Birth and Development
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Past Medical History
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Past Medical History Freewrite
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Past Surgical History
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Surgical history free text
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FAMILY HISTORY
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F/H of pulmonary/sleep disorders
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Positive family history of
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Free text Family history
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PERSONAL SOCIAL HISTORY
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Living arrangements
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Number of siblings
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Daytime arrangement, schooling
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Current or Former Smoker
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Smoking comments
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Alcohol Intake
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How much alcohol
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Caffeine intake
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Comments
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Substance abuse
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Substance abuse
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ROS
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General positive or negative
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General positive for
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Eyes positive or negative
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Eyes positive for
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Cardiovascular positive or negative
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Cardiovascular positive for
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GI positive or negative
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GI positive for
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Genito Urinary positive or negative
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Urinary positive for
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Musculoskeletal positive or negative
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MSK positive for
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Skin positive or negative
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Skin positive for
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Neuro positive or negative
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Neurological
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Endo positive or negative
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End positive for
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Ears WNL
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Ears positive for
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Heme WNL
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Heme positive for
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