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Height
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Weight
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How Often Do You Exercise?
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Alcohol Consumption
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Do you Smoke?
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Caffeine Consumption
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Why did you come to BHI today?
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Any Specific Concerns For Dr. Boone:
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(Physician Use) Additional Comments:
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How many hours do you sleep a day?
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Do you Snore loudly?
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Do you have difficulty falling asleep?
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Do you have difficulty staying asleep?
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Have you been diagnosed with sleep apnea?
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Do you use a sleep device or CPAP?
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Past Cardiac Medical History
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Medical History Concerns or Comments
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Hospitalization History:
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Past Surgical History:
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Past Surgical History Comments
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Any Additional Medical Concerns
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Father Medical History
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Additional Comments:
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Mother Medical History
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Additional Comments:
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Grandparents' Medical History
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Additional Comments:
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