• (972) 838-1892
  • PATIENT FORMS
  • 1701 Eldorado Pkwy Suite 250, Mckinney, TX 75069
  • Mon - Fri : 9:00 AM - 5:00 PM
  • Shahrukh A Kureishy M.d., F.C.C.P. Board Certified Pulmonologist
  • (972) 838-1892
  • PATIENT FORMS
  • 4833 Medical Center Drive, Suite 6B, McKinney, TX 75069
  • Mon - Fri : 9:00 AM - 5:00 PM
  • Shahrukh A Kureishy M.d., F.C.C.P. Board Certified Pulmonologist
  • (972) 838-1892
  • PATIENT FORMS
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PATIENT HISTORY

  • 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.

  • MM slash DD slash YYYY
  • EPWORTH sleepiness scale Questionnaire

  • PRINT IN CAPITAL LETTERS-STAY WITHIN THE BOX

  • Pounds
  • Years
  • COMPLETELY FILL IN ONE CIRCLE FOR EACH QUESTION- ANSWER ALL QUESTIONS

  • 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

    • Epworth Score
      TOTAL the
      values from all
      8 questions,
      If 11 or less
      Score = 0
      If 12 or more
      Score = 2
    • Score

    • Assign points for
      each of the first
      three responses

1701 Eldorado Pkwy Suite 250,
Mckinney, TX 75069

Call us : (972) 838-1892
Fax: 214-548-4205

Mon – Fri: 9:00AM – 5:00PM
Sat – Sun: Closed
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