JHRSDI-PAQ FORM - Jiva Health | Multi-Specialty Medical Clinic

Jiva Health Inc.
2182 East St,
Concord, CA 94520
Phone: (925) 685-4224 Fax: (925) 685-6997

REM Sleep Diagnostics Inc.
2601 Nut Tree Road, Suite C,
Vacaville, CA 95687
Phone: (707) 469-8400 Fax: (707) 469-8469

Contra Costa Sleep Center
2121 Ygnacio Valley Road E101,
Walnut Creek, CA 94598
Phone: (925) 944-0166 Fax: (925) 848-3999

Home Sleep Apnea Test Screening

Primary Care Physician (optional)

Referring Physician (optional)

1. Do you snore?

Yes No Don't Know

2. If you snore, is your snoring?

Slightly louder than breathing As loud as talking Louder than talking Very loud. Can be heard in adjacent rooms.

3. How often do you snore?

4. Has your snoring ever bothered other people?

Yes No

5. Has anyone noticed that you quit breathing during your sleep?

6. How often do you feel tired or fatigued after you sleep?

7. During your waketime, do you feel tired, fatigued or not up to par?

8. Have you ever nodded off or fallen asleep while driving a vehicle?

9. If you have nodded off or fallen asleep while driving, how often does it occur?

10. Do you have high blood pressure?

Yes No Don't Know

Home Sleep Apnea Test Screening

PERSONAL MEDICAL HISTORY: (please check any conditions you have had)

Please check all that are true for you

Other (Medical History)

Home Sleep Apnea Test Instructions

I have received one of the following Home Sleep Apnea Testing devices from Jiva Health.
I will carefully follow the instructions for the device received matching the picture below.

SleepImage Mobile App

You will need the Patient ID provided by Jiva Health

REMEMBER: Patient support can be reached at 800-818-4564

Failure to return the device after 48 hours serves as authorization to bill the responsible party the amount of $2000 for replacement of the device. I also agree to pay $25 per day beyond the return date and for all fees and costs associated with collecting this billable charge, including collection agency and attorney fees. These fees will be added to the purchase price.

Agreement

I consent to return the HSAT device after two consecutive nights use. I agree to pay $2000 for failure to return the device, plus $25 for each additional day beyond the expected return date. These fees and any costs associated with collecting this billable charge, including collection agency and attorney fees will be added to the overall cost of my Home Sleep Apnea Test (HSAT).

At Jiva Health, we offer services in primary and chronic care, medical weight management, diabetes, podiatry, endocrinology, sleep medicine, adult and pediatric allergy, immunology, and internal medicine.

We’re here to help you live your best life!

Book an appointment at our nearest multi-specialty medical clinic today.

Corporate Head Office: 2182 East St, Concord, California 94520, USA
Phone: 925-685-4224
Fax: 925-685-6997

Patient Assessment Questionnaire

Category 1

Category 2

Category 3

SleepImage Mobile App

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