Preparation Instructions for Sleep Study

PREPARATION INSTRUCTIONS FOR SLEEP STUDY

It is important that prior to undergoing your sleep study, you prepare appropriately. Please adhere to the following guidelines:

• Continue medications ordered by Physician.
• Do not consume any alcohol within 48 hours of your overnight study.
• Do not consume any caffeinated beverages after 8:00 a.m. on the day of your sleep study.
• Do not take any naps the day of your study.
• Eat a normal evening meal prior to coming to the SleepCenter.
• Take a shower and wash your hair prior to coming to the SleepCenter.
• Avoid using any hair products, including conditioner, hair sprays or mousse the day of the sleep study.
• Refrain from using skin lotions and powders.
• Do not bring large sums of money or jewelry with you.
• If you require special assistance in getting in and out of bed, you must bring an aid to be responsible for this care.

Please make sure to bring the following items to the hospital on the evening of your test:

• Bring comfortable and modest nightclothes. If you do not bring your own nightclothes, a hospital gown will be provided for you.
• Personal items needed for you to comfortably prepare for sleep, i.e. personal hygiene items, toothbrush, slippers, robe, etc.
• Your own pillow, if it will enhance a good night sleep.
• Any medication that you normally take during the hours that you will be at the hospital.
• If you are a diabetic, bring insulin and a snack.
• The completed sleep questionnaire, the Epworth Sleepiness Scale, and the Latex Allergy Questionnaire.

Parking: Two parking spaces have been designated on the East side of the SleepCenter.

Enter the hospital through the double glass doors on the East side.

• Announce yourself to the ER admissions clerk; complete a short registration process, and then
• You will be directed to the SleepCenter.

Once you arrive in the SleepCenter, a technician will direct you to a private bedroom that is specifically equipped to monitor and record your sleep activity. You will be asked to change into your nightclothes or hospital gown. Small sensors or electrodes will then be attached to your head and body. (A paste-like adhesive that dissolves in water is usually used, so no residue will be left in your hair when you shampoo after the procedure.) Flexible wiring is attached to the sensors, which is then connected to a central unit. A monitoring area is located close to your room. Once all of the sensors, electrodes and belts are attached, the technician will take some initial readings while you are awake. The set-up process can take 30-45 minutes or more in order to get everything connected properly.

The question everyone asks is, “Do you really expect me to sleep in all this?” Surprisingly, most people have little difficulty going to sleep wearing all the wires and sensors. After a patient is wired up, they’ll have some time to go back to their room and relax before the test begins. Even though there are many wires attached to the patient, going to the restroom during the night is easily done.

Please notify the technician if you have to be awakened by a specific time in the morning. You will be discharged from the SleepCenter no later than 7:00 a.m. on the morning following your test.

After you awake in the morning, the technician will help you remove the equipment and the paste-like substance. You are able to resume your normal activities as soon as possible.

Test results will be sent to your referring doctor.

PATIENT NAME:DATE OF BIRTH:

SEX:WEIGHT:HEIGHT:

WHAT DO YOU UNDERSTAND TO BE YOUR MAIN PROBLEM WITH SLEEP?

What time do you usually go to sleep? am/pm

What time do you usually arise? am/pm

How many hours do you sleep on average?

How long does it take to fall asleep Normally?

Do you have difficulty falling to sleep? YES NO
Do you awaken at night and can’t return to sleep? YES NO

Do you arouse from sleep? YES NO

If Yes, three or less times per night? YES NO

More than three times? YES NO

DAYTIME SLEEPINESS:

Are you rested after sleep? YES NO

Are you usually sleepy during the daytime? YES NO

Do you have trouble at work with sleepiness? YES NO

Have you fallen to sleep while driving? YES NO

Do you fall to sleep watching TV or reading? YES NO

How do you rate your sleepiness?

 Mild Moderate Severe

How many years has sleepiness been a problem?

OTHER SLEEP SYMPTOMS:

Do you snore loudly? YES NO

Have you been told you stop breathing during sleep? YES NO

How many years has this been a problem?

Do you awake with gasping or choking? YES NO

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Do you swing your arms/legs excessively during sleep? YES NO

Do you get sweats of the head and neck at night? YES NO

Do you awake with morning headaches? YES NO

Do you feel confused upon arousal? YES NO

Have you ever been told you have Narcolepsy? YES NO

Have others noticed you’ve become increasingly irritable? YES NO

Do you note feelings of anxiety? YES NO

Do you note feelings of depression? YES NO

Has your sexual interest or activity decreased recently? YES NO

Do other family members have sleepiness problems? YES NO

Have others commented that parts of your body jerk

during sleep? YES NO

Do you ever hallucinate at sleep onset? YES NO

Do you dream a lot? YES NO

Do you feel limp if you laugh or cry or feel surprise? YES NO

Are you ever unable to move when you first awaken? YES NO

MEDICAL DATA:

Do you have a history of high blood pressure? YES NO

Do you have a heart or lung disease? YES NO

Have you gained weight in the last two years? YES NO

If Yes, how many pounds?

Do you drink alcohol? YES NO

If Yes, how much?

Do you smoke? YES NO

Do you drink caffeinated beverages? YES NO

If Yes, how often?

List your medications:

THE EPWORTH SLEEPINESS SCALE

Name:Today’s Date: Age: Sex:

How likely are you to doze off or fall asleep in the following situations, compared to just feeling tired. This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation.

0 = would never doze

1 = slight chance of dozing

2 = moderate chance of dozing

3 = high chance of dozing

SITUATIONCHANCE OF DOZING

Sitting and Reading

Watching TV

Sitting inactive in a public place (meeting, theater)

As a passenger in a car for an hour without a break

Lying down to rest in the afternoon when

circumstances permit

Sitting and talking to someone

Sitting quietly after eating lunch without alcohol

In a car while stopped for a few minutes in traffic

Total Points

LATEX ALLERGY PATIENT QUESTIONAIRE

Patient Name: MR#:

1. Have you ever had allergies, asthma, hay fever, eczema or problems with rashes?

1. Have you ever had anaphylaxis or an unexplained reaction during a medical procedure?

1. Have you ever had swelling, itching or hives on your lips or around your mouth after blowing up a balloon?

1. Have you ever had swelling, itching or hives on your lips or around your mouth during or after a dental examination or procedure?

1. Have you ever had swelling, itching or hives following a vaginal or rectal examination or after contact with a diaphragm or condom?

1. Have you ever had swelling, itching or hives on your hands during or within one hour after wearing rubber gloves?

1. Have you ever had a rash on your hands that lasted longer than one week?

1. Have you ever had swelling, itching or hives after being examined by someone wearing rubber or latex gloves?

1. Have you ever had swelling, itching or hives, running nose, eye irritation, wheezing or asthma after contact with any latex or rubber product?

1. Has a physician every told you that you have rubber or latex allergy?

1. Are you allergic to bananas, avocados, chestnuts, pears, fig, papaya or passion fruit?

1. Are you presently on beta blockers?

Signature: Date:

Preparation Instructions03/20/03