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NURSE SECTION
BMI
Normal BMI 18.5 - < 25
Above Normal BMI =>25
Overweight (BMI 25-29)
Obesity Class 1 (BMI 30-34.9)
Obesity Class 2 (BMI 35-39.9)
Obesity Class 3 (BMI 40+)
History
Previous Dx Hypertension
Elevated Blood Pressure
Nicotine User
Cigarettes
Vape
Chewing Tobacco
Other
Nicotine Cessation Intervention Done?
Frequency of Use
Do you feel this is a habitual problem?
How motivated are you to quit?
Do you have a good support system at home?
Reasons for Quitting
What type of counseling or intervention is being provided to you?
• • •
Patient screened for food, housing, transportation, wellness, safety
Scales
Sleep Scales
Epworth Scale
1=Slight chance of dozing, 2=Moderate chance of dozing, 3= High chance of dozing
Sitting and Reading
Watching TV
Sitting Inactive in a Public Place
As a passenger in a car for an hr and no break
Lying down to rest in the afternoon when you can
Sitting and Talking to Someone
Sitting quietly after lunch without alcohol
In a car while stopped for few mins in traffic
Total Score:
Total item 1-17
Stop / Bang
Snoring, Tired, Observed Apnea, Blood Pressure
Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?
Do you often feel tired, fatigued, or sleepy during daytime?
Has anyone observed you stop breathing during you sleep?
Do you have or are you treated for high blood pressure?
BMI, AGE, Neck Circumference, Gender
BMI more than 30?
Age over 50 yrs old?
Neck circumference greater than 16 inches?
Gender Male?
BEARS (Pediatric)
Does my child have trouble going to bed? Or trouble falling asleep?
Does my child often seem tired during the day?
Does my child seem sleepy or groggy during the day?
Does my child snoring? Loudly? Nightly?
Is my child difficult to awake in the morning?
Is anything else interrupting my child's sleep?
Does my child gasp, stop breathing, or choke during the night?
Does this allow my child to get enough sleep every day?
How many hours of sleep does child need at this age?
When does your child go to bed? Weekdays
When does child get out of bed? Weekdays
When does child go to bed? Weekends
When does child get out of bed? Weekends
Narcolepsy Scale
How often are you unable to fall asleep?
How often do you take a nap during the day?
How often do you feel bad or not well rested in the morning?
How often have you experienced weak knees/buckling of the knees during emotions like laughing, happiness, or anger?
How often have you experienced sagging of the jaw during emotions like laughing, happiness, or anger?
Sleep Questionnaire
Reasons for Visit
Normal Wake Time:
Normal Bed Time
Hours of Sleep per Night
Previous Sleep Test
If yes....Where & When
Sleep Apnea [-]
Obstructive Sleep Apnea
Central Sleep Apnea
Gasping during sleep [-]
Shortness of Breath [-]
Snoring [-]
Asthma [-]
Excessive Sleepiness [-]
Seizures [-]
Feel unable to move (paralyzed) when waking for falling asleep [-]
Trouble falling asleep [-]
Headaches [-]
Frequent awakenings from sleep [-]
Back Problems [-]
Frequent Nightly Urinating [-]
Neck Pain [-]
Sleep Walking [-]
Diarrhea [-]
Sleep Talking [-]
Trouble concentrating [-]
Difficulty Swallowing [-]
Nasal Problems [-]
Smoke [-]
High Blood Pressure [-]
Drink Caffeinated Beverages [-]
Heart Attack [-]
Drink Alcohol [-]
Heart Disease / Heart Failure [-]
Dreams [-]
Pre-Diabetic [-]
Night Sweats [-]
Diabetes [-]
Leg movements / Leg kicks [-]
Loss of muscle tone when extremely emotional [-]
Naps [-]
Heartburn / Acid Reflux [-]
Act of out dreams [-]
Depression [-]
Use Alarm Clock [-]
Anxiety [-]
Weight Management Questionnaire
Nutrition Assessment Questionnaire
Why are you seeking a weight loss program?
What lifestyle changes will you need to make to have success in your weight loss journey?
How do you see yourself benefitting from successful weight loss?
Special Diets
Are you currently on a special diet?
What is your currently prescribed diet?
• • •
If Other, please describe
Weight loss programs previously attempted (select all that apply):
• • •
Plans to become pregnant?
Food Allergies
Please list any food allergies or intolerances:
Diet History
How long have you been overweight or obese?
Were you overweight as a child?
How much weight do you want to lose?
Eating Disorders
Have you ever received treatment for the following eating disorders?
• • •
If answered other please list condition
Have you ever used laxatives to control your weight?
Do you find yourself eating large amounts of food when alone?
Wake up in the middle of the night and eat?
Wake up in the morning to find evidence you have eaten, but don't remember?
Frequent skip meals?
Frequent crave sweets during the day?
Frequently fast as a part of your diet plan?
Are a vegetarian?
Drink alcohol?
Feel that there are goods that you cannot live without?
Experience problems with chewing or swallowing?
If you checked yes on any of the above, please explain:
Environmental Issues Affecting Your Weight
Occupational (working around food/no time for lunch)?
Sleep?
Travel?
Household?
Shopping or cooking?
Meals eaten away from home?
I get my groceries at:
• • •
Do you have a "good" supply (fruits, veggie, meat) for the month?
How long does your "good" food supply last?
If you do not have an adequate good supply for an entire month, what do you do?
List the people who will be there to support you during your weight loss journey:
Readiness For Change
Weight Loss: Check the statement below that BEST pertains to you right now:
• • •
Exercise: Check the statement below that BEST pertains to you right now:
• • •
Exercise Questionnaire
Do you have doctor-ordered restrictions on exercise?
What is currently limiting your physical activity?
Do you have a current exercise routine? If yes, explain:
What types of exercise have you performed in the past that helped you with weight loss?
Do you have a gym membership, and are you likely to use it?
What type of exercise equipment is available to you at home?
On a scale from 1-10, how motivated to exercise are you? (1-lowest, 10-highest)
If you are not currently exercising, do you have a plan to get started? If so, please explain:

H&P CC / History of Present Illness Medical Form

Sleep Medicine

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Published: Sept. 16, 2026, 9:36 a.m.
Provider: Dr. History Physical
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Sunnyvale, CA 94089

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