6410 Rockledge Drive Suite 610Bethesda, MD 20817Tel-301-530-9744

Directions to Our Bethesda OfficeFrom Gaithersburg/Frederick:Merge onto I-270 South towards WashingtonTake I-270 spur south toward I-495 south Northern VirginiaTake Exit Old Georgetown Rd/Rockledge Drive, take the ramp make a right at traffic light, stay on Rockledge Dr. “”do not make any turn”” cross Rockspring Rd traffic light. Our building is the last building on the right ***Champlain Building***

From Silver Spring: Merge onto Capital Beltway I-495 W Take the MD-187 exit 36 toward Old Georgetown Road/Bethesda/Rockville Merge onto MD-187 N/Old Georgetown Road toward Rockville Turn Right onto Democracy Blvd Turn Right onto Rockledge Drive Our building is the Champlain Building

From Northern Virginia: Merge onto I-495 North toward Maryland Merge onto I-270 N via exit 38 on the left toward Rockville/Frederick Take the Democracy Blvd exit Take the Democracy Blvd East ramp Merge onto Democracy Blvd Turn left onto Rockledge Drive Our building is the Champlain Building.

We Do Not Validate Parking Parking Fees:

16 min to 1 hour: $1.00Up to 2 hours: $2.00Up to 3 hours: $6.00Over 3 hours: $10.00

Mid-Atlantic Epilepsy & Sleep Center

You have been referred to the Mid-Atlantic Epilepsy and Sleep Center for the diagnosis of a possible sleep disorder. The following information will help you prepare for the visit to the sleep laboratory.

UPON ARRIVAL: You will not be able to enter the building after hours. When you arrive at 8:30 pm, the technician will be waiting in the lobby to escort you to the Sleep Center located on the 6th floor, Suite 610. If the tech is not there please call 301-988-1728 (Marc)

SCHEDULE: Plan to arrive on time, at 8:30 pm for your test. Please bring insurance card, picture I.D., and your completed paperwork.

THE SLEEP STUDY: The sleep study or polysomnogram is a combination of several diagnostics tests all recorded simultaneously during sleep. Brain wave activity or EEG will be recorded by attaching electrodes with adhesive to the scalp. Eye movements and chin muscle will also be monitored in this manner. Depending on your physician’s request, other monitors may be applied to monitor breathing, airflow and oxygen level. The equipment may be minimally uncomfortable, but does not prevent sleep or interfere with a meaningful sleep study.

PEDIATRIC PATIENTS: All patients 17 years of age and younger require an adult accompany them to the Sleep Center and stay for the duration of the Polysomnogram. The parent/guardian will not be permitted to stay in the patient room while the study is being acquired. Accommodations will be made in the Sleep Center for the parent.

PLEASE BE ADVISED, IF YOU NEED TO CANCEL YOUR SLEEP STUDY FOR ANY REASON, WE REQUIRE A 48 HOUR NOTICE. IF YOU DO NOT SHOW UP FOR YOUR APPOINTMENT AND NO PRIOR NOTICE WAS GIVEN, YOU WILL BE CHARGED A $200.00 FEE.

Once the study has started, you have the right to discontinue the test for any reason, however please be aware that a shorter test may not be as reliable or as useful for the interpreting physician. The full charge for the study will be submitted for payment. Sleep Center patients cannot stay in the lab and sleep without properly being monitored. Therefore, please make sure that if you decide to discontinue your test during the middle of the night, that you have proper arrangements for getting home, as you may not be allowed to drive yourself if you are sleep deprived.

Please read this…

MANDATORY PATIENT INSURANCE INFORMATIONWe have enclosed a registration form and a questionnaire that we need for you to complete before we can perform your diagnostic test at the Mid-Atlantic Epilepsy & Sleep Center. Please complete these forms at home and bring them in with you the night of your procedure. If you wait until you arrive to complete these forms, it will delay your testing that evening. These forms must be COMPLETELY filled out.REMINDER:Bring your **INSURANCE CARD** and a **PHOTO ID** with you so that a copy can be made for your chart.VERY IMPORTANT:Please Check With Your Insurance Provider To See If Pre-Authorization and/or An Insurance Referral Form Is Required. Pre-authorizations and Referrals are NOT the same and some insurance companies require both.WAYS TO MAKE YOUR STUDY COMFORTABLE:DON’T:1. DO NOT nap in the afternoon before your sleep study, if possible.2. No alcohol or caffeine consumption on the day of the test after 12 noon.3. Nail polish or acrylic nails are to be removed. If you have nail polish or acrylic nails on when you arrive for your study, the technician will have to remove the nail polish and/or the acrylic nail from one finger. This is necessary for accurate oxygen saturation readings during the study.4. DO NOT use hair care products on your hair the night of your study. For example, hair spray, hair gels, creams, etc.5. DO NOT wear make-up or lipstick the night of your study or use heavy creams on your face.DO:1. Eat dinner, shower and shampoo your hair the day of your study. 2. Bring:• All your medications. We do not have medications at the center, nor can we obtain them for you. This includes prescription and non-prescription medication, i.e., Tylenol, Aspirin, etc.• Bed Clothes. Bring something comfortable to sleep in, including a bathrobe and slippers. Keep in mind that either a male or female technician will monitor you.• Toiletries. Bring whatever you may need to spend a night away from home, i.e., tooth brush, tooth paste, etc.• Pillow. Most people sleep better with their own.KEEP IN MIND:1. This is a medical procedure and we are an outpatient facility.2. We do not have a shower facility available3. Male and female technicians could be on staff to monitor you. 4. Technicians are not allowed to give out any information about your test results. Please ask your physician or Dr. Klein if you have any questions about the results of your study.5. Preliminary results will be faxed to your referring physician within 3 working days

INITIAL QUESTIONNAIRE

*Patient, when receiving this via e-mail, please print out this entire questionnaire, and bring it with you on the night of your study.

PLEASE ANSWER THE FOLLOWING QUESTIONS AS COMPLETELY AND ACCURATELY AS YOU CAN. ALL ANSWERS ARE KEPT CONFIDENTIAL.

Name: Date: Last Name First Name M.I.

Home Address:

City: ____________________________________________ State: ________________ Zip:

Home phone: ( ) Work phone: ( ) Mobile phone: ( )

Occupation:

Birth Date: Age: Sex: Height: Weight:

Referring Physician:

Physician’s Address:

Physician’s phone number: Fax:

Family Physician (if different from referring):

Family Physician’s address:

Family Physician’s Phone number: Fax:

Insurance Company: ID#: Group#:

Insured Name: Birth Date:

SLEEP HISTORY

1. Do you have trouble getting to sleep at night? never rarely sometimes frequently

2. On the average, how long does it take you to fall asleep?

3. Are you bothered by frequent awakenings? Yes No

4. On the average, how often during the night do you wake up?

5. Are you bothered by long periods of wakefulness during the night? never rarely sometimesfrequently

If yes, how much time altogether do you spend in such wakefulness during the night?

6. Are you bothered by waking up too early and not being able to get back to sleep? never rarely sometimes frequently

7. Are you bothered by nightmares? never rarely sometimes frequently

8. Do you awaken from sleep short of breath? never rarely sometimes frequently

9. Do you snore loudly enough that your spouse or others complained about it? never rarely sometimes frequently

10. How often do you have a sleep problem? never rarely sometimes frequently

11. On the average, how long do you actually sleep at night? ________hours.

12. Do you feel tired during the day? never rarely sometimes frequently

13. Do you have any health problems? Please describe.

13. Do you take any medications (pills, shots, vitamins, herbs, etc.)?If yes, list below the names and amounts of all medications you are taking and state how often and why you take each one.

Medication Dose How often Reason

15. Write in the average amount of each of these beverages that you drink per day.

natural coffee cups per daydecaffeinated coffee cups per daytea cups or glasses per daycarbonated soft drinks cups or bottles per dayalcoholic beverages glasses per day

16. How long have you had your sleep problem?

17. Do you take naps? never rarely sometimes frequently

18. Did you nap today? If so, at what time? Yes No If yes, what time did you take a nap and how long was the nap?

________________________________________________________________________________________

19. Are your sleep habits on weekends different from those of the rest of the week? Yes No

20. What time do you usually go to bed and get up?Weekdays: go to bed AM PM

get up AM PMWeekends: go to bed AM PM

get up AM PM

How likely are you to doze off or fall asleep in the following situations? How often do you feel 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 evaluate how they would affect you. Use the following scale to choose the most appropriate number for each situation:

0 = would never doze1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozing

Situation Chance of dozing

Sitting and reading

Watching TV

Sitting, inactive, in a public place (e.g., a theater or a meeting)

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

Lying down to rest in the afternoon when circumstances permit

Sitting and talking to someone

Sitting quietly after a lunch without alcohol

In a car, while stopped for a few minutes in traffic

21. Do you ever feel confused when you awaken from sleep? never rarely sometimes frequently

22. Do you feel refreshed after a short (10 to 15 minutes) nap? Yes No

23. Does your sleepiness appear to be worse three to four times per day?

never rarely sometimes frequently

24. Does your sleepiness occur at fairly predictable intervals? Yes No

25. Do you awaken in the morning with headaches? never rarely sometimes frequently

26. Do other people tell you that you are restless during sleep? Yes No

27. Have others noticed that you have become increasingly irritable or short-tempered? Yes No

28. Has your sexual activity decreased recently? Yes No

29. Do you find that your mind is not working as quickly or effectively as it used to? Yes No

30. When you awaken in the morning, how long does it usually take for you to begin functioning normally?

0-15 min. 15-30 min. > 30 min.

31. Do you perspire a great deal at night? never rarely sometimes frequently

32. When you are angry or laugh, do you ever feel weak, as though you might fall? never rarely

sometimes frequently

33. Do other members of your family have sleeping problems? Yes NoDescribe how you feel when you wake up in the morning.

34. Do your ankles ever swell? Do you have trouble getting your shoes on and off? never rarely sometimes frequently

35. Do you have difficulty with your sexual functioning never rarely sometimes frequently

36. Are you in good health? Yes No

37. Year of last complete physical examination:

Examining physician’s name:

Physician’s address:

Office telephone number: M.D.’s specialty:

38. Was anything found wrong in your last physical examination? Yes No

If yes, describe:

REMARKS: If there are any other aspects of your sleep problem which you feel are important, please describe

them in the space below. Also, list any medications that were not listed above.

_________________________________________________________

THE EPWORTH SLEEPINESS SCALE

Name: Age:

Today’s Date: Male Female

How likely are you to doze off or fall asleep in the following situations, in contrast to 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 choose the most appropriate number for each situation:

0 = would never doze1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozing

SITUATION CHANCE OF DOZING

Sitting and reading

Watching TV

Sitting, inactive in a public place ( e.g. a movie theatre or a meeting )

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

Lying down to rest in the afternoon when circumstances permit

Sitting and talking to someone

Sitting quietly after lunch without alcohol

In a car, while stopped for a few minutes in the traffic

- Assignment and Release -I certify that I, and/my dependent, has insurance coverage with_________________________________ and assign directly to Dr. Pavel Klein all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named physician may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

_____________________________________________________________________________________Signature of Patient, Parent, Guardian or Personal Representative Date

_____________________________________________________________________________________Please print name of Patient, Parent, Guardian or Personal Representative Relationship to Patient

- Patient Responsibility -

I understand that if my insurance plan requires a referral from my primary care physician for specialty consultation and/or services, and that it is my responsibility to ensure that Mid-Atlantic Epilepsy & Sleep Center (Dr. Pavel Klein) have that referral at the time of services. If services are rendered under circumstances when referral has reportedly been made, but was not immediately available, the referral must be received in our office within two working days of services rendered. I will be held responsible for all services rendered if referral is not received, services rendered are not specified on the referral, and date of referral does not cover date services are rendered.

I hereby affirm to the best of my knowledge, am a duly enrolled member of insurance company. I understand that I am financially responsible for all services rendered if my coverage is not in effect at the time of my visit. In such case I agree to pay Mid-Atlantic Epilepsy & Sleep Center (Dr. Pavel Klein) usual and customary charges for all services rendered.

___________________________________________________________________________________________________________________Signature of Patient, Parent, Guardian or Personal Representative Date

_____________________________________________________________________________________________________________________________________Please print name of Patient, Parent, Guardian or Personal Representative Relationship to Patient

- Patient Acknowledgement -

I have received the NOTICE of PRIVACY PRATICES and I have been provided an opportunity to review it.

Name______________________________________________ Birthdate _________________

Signature ____________________________________________________________________

Date ________________________________________________________________________