Dr. Arina Bingeliene Consultation Form | Etobicoke Brampton Sleep Clinic

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Personal Information & Patient Contact

First Name:

Last Name:

DOB (Date of Birth):

Gender:

Street Address:

City:

Postal Code:

Telephone - Home:

Work/Cell Phone:

Email Address:

Health Card Number:

Version Code:

Marital Status:

Valid Driver's License? Yes No

Family Physician Contact Information

Family Doctor Name:

Telephone Number:

Fax Number:

Clinic Street Address:

City:

Postal Code:

Doctor's Email Address:

Other Physicians / Specialists to Inform:

General Questions & Medical Background

Please briefly describe your current sleep difficulty, concern, or other problem:

Please list chronic medical problems, prior surgeries, or mental health disorders:

Are you allergic to any medications? Yes No

If Yes, Please List Allergies:

Please list all medications you are taking and the doses:

1 Dose

2 Dose

3 Dose

4 Dose

5 Dose

6 Dose

7 Dose

8 Dose

9 Dose

10 Dose

Is there a family history of Sleep Apnea, Insomnia, or Restless Legs Syndrome (RLS)?

Yes No

Health Habits & Personal Safety Questions

On average, how much caffeine do you take in each day?

Coffee (Cups per day):

Tea (Cups per day):

Cola (Cans per day):

On average, how much alcohol do you drink per week?

Beer (Cans per week):

Wine (Glasses per week):

Liquor (Ounces per week):

Nicotine & Tobacco Exposure

Do you currently smoke cigarettes? Yes No

If yes, how many cigarettes per day?

Do you currently use cannabis?

Yes No

Do you exercise regularly?

Yes No

The Epworth Sleepiness Scale (ESS)

Scoring Key Matrix:

0 Would NEVER doze

1 SLIGHT chance

2 MODERATE chance

3 HIGH chance

Situation Context	Chance of Dozing (0 - 3)
Sitting and reading	0 1 2 3
Watching television	0 1 2 3
Sitting inactive in a public place (e.g. in a theatre or a meeting)	0 1 2 3
As a passenger in a car for an hour without a break	0 1 2 3
Lying down to rest in the afternoon when circumstances permit	0 1 2 3
Sitting and talking to someone	0 1 2 3
Sitting quietly after a lunch without alcohol	0 1 2 3
In a car, while stopped for a few minutes in traffic	0 1 2 3

Epworth Score Total: 0 / 24

Sleep Architecture & Routine Matrix

What is your usual bedtime?

What is your usual wake time?

Time to fall asleep (Minutes):

Nightly awakenings count:

Time to return to sleep:

Naps per week:

Nap duration:

Are naps refreshing? YES NO

Dream during naps? YES NO

Submission Form Locked

To complete and securely submit this Pre-Consultation Questionnaire, please click here to log in .

Dr. A. Bingeliene Consultation Form

Epworth Score Total: 0 / 24

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