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Dr. Damiana Corca | 4440 Arapahoe Ave, Suite 215, Boulder, CO 80303 | 303-440-1033 | damianacorca.com

May 2, 2024

First Patient's Name

First Name*

Last Name*
First Patient's Date of Birth*
First Patient's Information

What have you done so far for your sleep and why are you seeking care? *
First Patient's Signature*
Second Patient's Name

First Name*

Last Name*
Second Patient's Date of Birth*
Second Patient's Information

What have you done so far for your sleep and why are you seeking care? *
Third Patient's Name

First Name*

Last Name*
Third Patient's Date of Birth*
Third Patient's Information

What have you done so far for your sleep and why are you seeking care? *
Fourth Patient's Name

First Name*

Last Name*
Fourth Patient's Date of Birth*
Fourth Patient's Information

What have you done so far for your sleep and why are you seeking care? *
Fifth Patient's Name

First Name*

Last Name*
Fifth Patient's Date of Birth*
Fifth Patient's Information

What have you done so far for your sleep and why are you seeking care? *
Sixth Patient's Name

First Name*

Last Name*
Sixth Patient's Date of Birth*
Sixth Patient's Information

What have you done so far for your sleep and why are you seeking care? *
Seventh Patient's Name

First Name*

Last Name*
Seventh Patient's Date of Birth*
Seventh Patient's Information

What have you done so far for your sleep and why are you seeking care? *
Eighth Patient's Name

First Name*

Last Name*
Eighth Patient's Date of Birth*
Eighth Patient's Information

What have you done so far for your sleep and why are you seeking care? *
Ninth Patient's Name

First Name*

Last Name*
Ninth Patient's Date of Birth*
Ninth Patient's Information

What have you done so far for your sleep and why are you seeking care? *
Tenth Patient's Name

First Name*

Last Name*
Tenth Patient's Date of Birth*
Tenth Patient's Information

What have you done so far for your sleep and why are you seeking care? *
Parent or Guardian's Email Address

Email*

Confirm Email*
Please fill out this form and we will be in touch for next steps.

Please complete the following questionnaire by filling in the blanks and placing a check in appropriate areas. 

My Main Sleep Complaint(s) Is:

Trouble falling asleep at night
Waking up in the middle of the night
Waking up early
Being sleepy all day
Snoring
Waking up choking or gasping for air or have been told to be choking at night
Unwanted behaviors during sleep
Other

If unwanted behaviors during sleep or other, please explain:

Sleep Pattern


Typical bedtime *

Typical wake up time: *

Typical number of awakenings per night: *

Typical time you usually wake up at night? *

Total amount of sleep per night: *

Number and duration of naps per day: *

List any activities that you normally do during nighttime awakening(s), i.e. restroom, eat, watch TV:

Please check all of the following statements that are true about your sleep:

Habits and Symptoms During Wake Times at Night

I have physical tension or restlessness
I grind my teeth
I have restless legs
I feel bloated and/or hungry
I have itchiness
My mind is calm and quiet and I am able to think about projects, watch TV, or read
My mind is irritated, confused and tired, I am unable to read or concentrate

Dreams

I have dreams of control / direction / movement / navigation
I have dreams of loss of home / property / territory / valuables
I have dreams of vulnerability, exposure, and shame
I have dreams of threat, danger, feelings of fear, nightmares
I have night terrors, dreams of guilt, unfinished business, non-acceptance

Daytime Sleepiness

I have a tendency to fall asleep during the day
I have had "blackouts" or periods when I am unable to remember what just happened
I have fallen asleep while driving
I fall asleep while watching TV
I fall asleep during conversations
I fall asleep in sedentary situations
I have had injuries as the result of sleepiness
I performed poorly in school because of sleepiness
I have had an inability to move while falling asleep or when waking up
I have had hallucinations or dreamlike images or sounds when falling asleep or waking up

Habits

I drink caffeinated beverages during the day*
No
Yes

Cups/bottles/cans per day:

Time of the last caffeinated drink:
Do you drink alcoholic beverages?*
No
Yes

What kind of alcoholic drinks and how much? Have you noticed if it affects your sleep?
Do you smoke?*
No
Yes

What do you smoke and how often?

Social History

Sleep alone
Share a bed with someone
My job requires driving a vehicle
I work with dangerous equipment or substances
I am a shift worker on rotating shifts
I am a permanent or long-term, third-shift worker

Sleeping Environment

There is some amount of light in my bedroom at night*
No
Yes

Specify sources(s)
There are noises at night in my bedroom*
No
Yes

Specify sources(s)
I use electronics in my bedroom (i.e. cell phone, TV, iPad, etc...)*
No
Yes

Specify sources(s)

Temperate of room you sleep in (Farenheit): *

Past Sleep Evaluation and Treatment

I have had a previous sleep disorder evaluation
I have had a previous overnight sleep study
I have been prescribed, mandibular advancement device, CPAP or bilevel PAP machine for home use
I have had surgical treatment for a sleep disorder
I have previously been prescribed medication for a sleep disorder
I have previously been treated for a sleep disorder

If you have been prescribed medication, please describe type of medication, also what helped, what did not help.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

What have you done so far for your sleep and why are you seeking care? *
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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