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Neurology Center of Fairfax is implementing Patient Connect by Luma as a way for you to complete your forms online before coming to the office.
You will receive a text from (703) 574-0867 with your appointment confirmation, reminders, and forms link.
Please call our office with any questions.

forms-header

Sleep Health Update

Sleep Health Update

URL

This field is for validation purposes and should be left unchanged.

Patient first name(Required)

Last name(Required)

Email(Required)

Enter Email Confirm Email

Date of Birth(Required)

Date(Required)

MM slash DD slash YYYY

Please write today’s main problem/concern

What time do you usually go to bed?

How long does it take you to fall asleep?

Do you take any sleep aids?

Yes

No

How often?

Do you wake up at night?

Yes

No

How many times?

Please list reasons you wake up…

What time do you usually wake up in the morning?

Do you feel refreshed?

Always

Sometimes

Never

Are you sleepy during the day?

Always

Sometimes

Never

Do you doze off or take naps?

Always

Sometimes

Never

Do you fall asleep while driving?

Always

Sometimes

Never

Any motor vehicle accidents?

Yes

No

Do you use a CPAP machine?

Yes

No

Please answer the following if you use a CPAP machine:

What type of mask do you use?

Nasal mask

Full face mask

Nasal pillows

Are you having problems with your CPAP mask?

Yes

No

Do you have significant morning dry mouth?

Yes

No

Which company supplies your CPAP equipment?

How likely are you to doze off or fall asleep in the following situations?

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

Sitting and reading

0

1

2

3

Watching TV

0

1

2

3

Sitting quietly in a public place (i.e. theatre or meeting)

0

1

2

3

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

0

1

2

3

Lying down to rest in the afternoon when able to

0

1

2

3

Sitting and talking to someone

0

1

2

3

Sitting quietly after lunch without alcohol

0

1

2

3

In a car, while stopped for a few minutes

0

1

2

3

Rev 9.7.2022

Locations

Fairfax Office
3020 Hamaker Ct, Suite 400
Fairfax, VA 22031
703-876-0800 | Fax: 703-876-0866

Reston Office
1830 Town Center Drive, Suite 305
Reston, VA 20190
703-876-0800 | Fax: 703-876-0866

Sleep Diagnostic and Treatment Center
3020 Hamaker Ct, Suite 400
Fairfax, VA 22031
703-876-2850 | Fax: 571-308-1158

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