Mercy Sleep Intake Tool
Sleepiness & Metrics
Sleep History
What is your primary sleep complaint?
Have you had a previous sleep study?
If yes, when and where?
Have you ever been diagnosed with a sleep disorder?
Have you used CPAP at home?
If currently using CPAP, what is the reason for this study?
Is this study being done to see if you qualify for the Inspire® device?
Do you currently use supplemental oxygen at home?
Medications
List medications taken today that help with sleep, wakefulness, pain, anxiety/depression, or other relevant conditions.
Pertinent Medical History Please check all conditions that have been diagnosed by a physician
Cardiovascular & Metabolic
Neurological & Psychiatric
Pulmonary, Pain & Other
Surgical History
Symptoms Please check all that apply based on your own experience or what others have told you
Sleep Apnea
Sleep Behavior
Restless Legs
Insomnia
Report Narrative
No intake data entered.