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(If different from patient)

Insurance Information

DOB MM/DD/YYYY
SelfSpouseParentChildOther
Subscriber

Second Insurance

DOB MM/DD/YYYY
SelfSpouseParentChildOther
Subscriber
Not at allSeveral DaysMore than half the daysNearly everyday
1. Little interest or pleasure in doing things.
2. Feeling down, depressed, or hopeless
3. Trouble falling or stay asleep too much
4. Feeling tired or having little energy.
5. Poor appetite or overeating.
6.Feeling bad about yourself - or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching tv.
8. Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting self.
Not difficult at allSomewhat difficultVery difficultExtremely difficult
10. If you have checked off any problems , how difficult have these problems made it for you to do your work, take care of things at homes, or get along with people?

PHQ-9 Patient Depression Questionaire

For initials diagnosis:  
  1. Patient completes PHQ-9 Depression Assessment.
  2. If there are at least 4 ✓’s in the shaded section (including Question #1 and #2), consider a depressive disorder. Add Score to determine severity.
 

Consider Major Depressive Disorder

  • If there are at least 5 ✓s in the shaded section (one of which corresponds to question #1 and #2)
 

Consider Other Depressive Disorder

  • If there are 2-4 ✓s in the shaded section (one of which corresponds to question #1 and #2)
  Note: Since the questionnaire relies on patient self-report, all responses should be verified by the clinician, and a definitive diagnosis is made on clinical grounds taking into account how well the patient understood the questionnaire, as well as other relevant information from the patient. Diagnoses of Major Depressive Disorder also require impairment of social, occupational, or other important areas of functioning (Question #10) and ruling out normal bereavement, a history of a Manic Episode (Bipolar Disorder), and a physical disorder, medication, or other drug as the biological cause of depressive symptoms.    To monitor severity over time for newly diagnosed patients in current treatment for depression:  
  1. Patients may complete questionnaires at baseline and at regular intervals (eg, every 2 weeks) at home and bring them in at their next appointment for scoring or they may complete the questionnaire during each scheduled appointment. 
  2. Add up ✓s by column. For every ✓: Several days = 1 more than half the days = 2 nearly every day = 3
  3. Add together column scores to get a TOTAL score. 
  4. Refer to accompanying PHQ-9 Scoring Box to interpret the TOTAL score.
  5. Results may be included in  patient files to assist you in settings up treatment goal, determining degree of response, as well as guiding treatment intervention.
  Scoring: Add up all checked boxes on PHQ-9.   For every ✓ Not at all = 0; Several days = 1; More than half the days = 2; Nearly every day = 3   Interpretation of Total Score  
Total Score Depression Severity
1-4 Minimal depression
5-9 Mild depression
10-14 Moderate depression 
15-19 Moderately severe depression
20-27 Severe depression
PHQ9 Copyright © Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MD ® is a trademark of Pfizer Inc.    A2662B 10-04-2005 EPWORTH SCALE   How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you “Have Not’ done some of these recently, try to work out how they would affected you. Use the following scale to choose the most appropriate number of each situation:  
0 No Chance of Dozing
1 Slight Chance of Dozing
2 Moderate Chance of Dozing
3 High Chance of Dozing
0123
Sitting & Reading
Watching T.V.
Sitting Inactive in a public place (e.g. movies/theater)
As a passanger 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.
YesNo
Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors)?
Do you often feel TIRED, fatigued, or sleepy during daytime?
Has anyone OBSERVED you stop breathing during your sleep?
Do you have or are you being treated for high blood PRESSURE?
BMI more than 35kg/m2?
Age over 50 years old?
Neck circumference > 16 inches (40cm)? Yes No
Gender: Male?
High Risk of OSA: Yes 5-8 , Intermediate risk of OSA: Yes 3-4 , Low Risk of OSA: Yes 0-2

ASSIGNMENT OF INSURANCE BENEFITS

I hereby authorize direct payment of consultations/sleep study benefits to Dr. Gonzalo Diaz/ El Paso sleep Center for services rendered by him/her in person or under his/her supervision. I understand that I am financially responsible for any balance not covered by my insurance.

AUTHORIZATION TO RELEASE INFORMATION

I hereby authorize the doctor to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefit. MEDICARE/MEDICAID

Hi, certify that the information given by me in applying for payment is correct. I authorize the release of all records on request. I requested payment of authorized benefits be made on my behalf. AUTHORIZATION OF PATIENTS RELEASE OF INFORMATION

During the course of your treatment at the El Paso sleep Center the doctor may prescribe a CPAP unit for you to use at home. If the op Paso sleep Center is not in the network of your particular insurance, the old Paso sleep Center will forward your information to a medical equipment company to provide you with any medical equipment that may be necessary.

I authorize El Paso sleep center to release patient information to a medical equipment company that would be able to further assist me in regards of receiving the CPAP unit or any other medical supplies.