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The following document
contain a series of
questions regarding your
family history, personal
background and medical
history. Please indicate
your response to each
question by checking where
indicated or printing your
answer in the space
provided. If you are unable
to answer any question just
leave the space/box blank.
Please review each question
carefully as the accuracy of
your response is important.
The information you provide
will enhance our evaluation
of any sleep problems you
may be experiencing. This
document will remain in your
file and all information
will be treated with the
same confidentiality that
your other medical records
receive.
You should request assistant
from family members or your
sleep mate for questions
about your activities during
your normal sleep period.
Also, other family members,
friends, family doctor, etc.
may be able to supply
history and medical
information that you are
unaware of. Of course, if
there is information that we
failed to ask for and that
you feel might be important
for us to know, please add
that to this questionnaire.
An extensive sleep history
will be or was taken during
your initial visit with the
Sleep Physician. Prior to
arriving at Sleep
Diagnostics’ Sleep Center
please have the attached
questionnaire completed to
the best of your ability.
Answer all questions
objectively and accurately
as this information will
guide us in compiling
diagnostic data for the
Sleep Physician to review.
If you have any questions or
problems regarding this
questionnaire please call
the Sleep Center at
631-675-0830. If no one is
there to take your call
please leave a message as we
frequently retrieve our
messages and will return
your call.
Please bring photo
identification such as a
driver’s license and all
your insurance cards to all
appointments.
Click here to
Download the document
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Sleep Diagnostics Group, LLC
2500 Nesconset Highway, Building 8C Stony
Brook, NY 11790
Tel. 631-675-0830 Fax 631-675-0829 |
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