Office Visit Questionnaire

If you are coming in for a visit (new patient or follow-up) you need to complete these forms. This applies to telemed visits as well. Please contact our office if you have any questions.

Office Visit Questionnaire

Name*
First Last
Email*
Gender*
- Male
- Female
Epworth Sleepiness Scale
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? Even if you haven’t done some of the these activities recently, think about how they would have affected you. 0=would never doze 1=slight chance of dozing 2=moderate chance of dozing 3=high chance of dozing
Sitting and reading*
- 0=would never doze
- 1=slight chance of dozing
- 2=moderate chance of dozing
- 3=high chance of dozing
Watching television*
- 0=would never doze
- 1=slight chance of dozing
- 2=moderate chance of dozing
- 3=high chance of dozing
Sitting inactively in a public place (e.g. a theater or meeting)*
- 0=would never doze
- 1=slight chance of dozing
- 2=moderate chance of dozing
- 3=high chance of dozing
As a passenger in a car for about an hour without a break*
- 0=would never doze
- 1=slight chance of dozing
- 2=moderate chance of dozing
- 3=high chance of dozing
Lying down to rest in the afternoon*
- 0=would never doze
- 1=slight chance of dozing
- 2=moderate chance of dozing
- 3=high chance of dozing
Sitting and talking*
- 0=would never doze
- 1=slight chance of dozing
- 2=moderate chance of dozing
- 3=high chance of dozing
Sitting quietly after lunch (without alcohol)*
- 0=would never doze
- 1=slight chance of dozing
- 2=moderate chance of dozing
- 3=high chance of dozing
In a car while stopped in traffic*
- 0=would never doze
- 1=slight chance of dozing
- 2=moderate chance of dozing
- 3=high chance of dozing
Consent*
I agree to this statement.
I understand I should only drive when fully alert. I should NOT drive, operate machinery, or perform any hazardous task when drowsy or sleepy.
Medical and Billing Release
Dr. Gardner and Dr. Charnock and their staff have my permission to discuss my medical condition, medical treatment and medical billing information with the following people.
Medical and Billing Release
Name Relationship Phone Number

Dr. Gardner and Dr. Charnock and their staff have my permission to discuss my medical condition, medical treatment and medical billing information with the following people.
Medical and Billing Release
Name Relationship Phone Number

Dr. Gardner and Dr. Charnock and their staff have my permission to discuss my medical condition, medical treatment and medical billing information with the following people.
Medical and Billing Release
Name Relationship Phone Number

Dr. Gardner and Dr. Charnock and their staff have my permission to discuss my medical condition, medical treatment and medical billing information with the following people.

Name	Relationship	Phone Number

Name	Relationship	Phone Number

Name	Relationship	Phone Number

Office Visit Questionnaire

Office Visit Questionnaire

Epworth Sleepiness Scale

Medical and Billing Release