HOME SLEEP TEST APPLICATION Please email to:
[email protected] Or fax to: (702)-990-7665 Date: All Questions contained in this questionnaire are strictly confidential and will become part of your medical record. Last Name - Miranda First Name - Karen M F [_] [V] DOB - 01/07/1987 Address - 160 Cielo Abierto Way City - Las Vegas State - NV Zip - 89012 Email
[email protected] Home Phone Cell Phone - 702-477-9151 Employer Job Title MEDICAL INSURANCE INFORMATION (Insurance companies require the information below for billing purposes) Do you have insurance? Yes No [V ] [_] If not, which method will you pay with? Cash [_] Check [_] Credit [_] Name of Primary Insurance Company - Anthem Name of the Insured/Subscriber - Karen Miranda Insured’s SSN # 450-83-4049 Relationship to Patient - Patient Policy # VQX178W22514 Group ID L12133M010 Insurance claims mailing address 160 Cielo Abierto Way #913 Las Vegas, NV 89012 Insurance telephone Number 1-833-592-9956 MEDICAL INFORMATION (Insurance companies require the information below for billing purposes) Height (inches) 68.4 Weight (pounds) 320 Neck Size (inches) 18 “STOP” SLEEP SCREENER If you check YES to two or more of these questions, you are at risk for unhealthy sleep. S (Snore) Do you snore? Yes No [Y] [_] T (Tired) Do you feel fatigued during the day? Yes No [Y] [_] O (Obstruction) Have you been told you stop breathing at night – OR – Do you gasp for air or choke while sleeping? Yes No [Y] [_] P (Pressure) Do you have high blood pressure – OR – Are you on medication for high blood pressure? Yes No [Y] [_] “BANG” SLEEP SCREENER Each YES you check here increases your risk of moderate to severe unhealthy sleep. B (BMI) Is your body mass index greater than 28? (You can calculate this online) Yes No [Y] [_] A (Age) Are you 50 years old or older? Yes No [_] [n] N (Neck Are you a: male with a neck circumference greater than 17” – OR – a female with a neck circumference greater than 16”? Yes No [Y] [_] G (Gender) Are you a male? Yes No [_] [n]
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