METROPLEX PULMONARY & SLEEP CENTER, P.A
4833 Medical Center Drive, Suite 6B McKinney, Texas 75069
Phone: 972- 838-1892 Fax: 972-838-1896 or 972-954-6030

PATIENT HISTORY FORM

Other Hospitalizations:

Current Medications: Please list all medications you are currently taking. We can also make a copy of your medication list if you have it with you.

PRINT IN CAPITAL LETTERS-STAY WITHIN THE BOX

Epworth Sleepiness Scale: How likely are you to doze off or fall asleep in the following situations, in contrast 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 mark the most appropriate box for each situation. (M.W. Johns, Sleep 1991)

0 = would never doze
1 = slight chance of dozing
2 = moderate change of dozing
3 = high chance of dozing