SLEEP PATIENT PERSONAL INFORMATION & CONSENT TO PROCEDURE FORM

We require you to fill out the below questionnaire to assist in determining your eligibility for Level 3 sleep testing during the COVID-19 pandemic to provide a safe environment for staff, physicians, contractors, patients and families. The information in this questionnaire is collected under the authority of FOIP section 33 (c) and will be used and disclosed solely for the purposes of safety during the COVID-19 pandemic. The questionnaire intends to identify new symptoms or worsening of symptoms.

Risk Assessment: Screening Questions

Patient Name:*

Date of Birth:

Phone Number

Do you have any of the following symptoms which are new or worsened if associated with allergies, chronic or pre-existing conditions: fever, cough, shortness of breath, difficulty breathing, sore throat, and/or runny nose?

Yes
No

Have you returned to Canada from outside the country (including USA) in the past 14 days?

Yes
No

In the past 14 days:

Did you have close contact* with someone who has a probable** or confirmed case of COVID-19 ?

Yes
No

Did you have close contact* with a person who had acute respiratory illness that started within 14 days of their close contact* to someone with a probable** or confirmed case of COVID-19?

Yes
No

Did you have close contact* with a person who had acute respiratory illness who returned from travel outside of Canada in the 14 days before they became sick?

Yes
No

Did you have a laboratory exposure to biological material (i.e. primary clinical specimens, virus culture isolates) known to contain COVID-19?

Yes
No

If you answer “YES” to any of the above, you are not permitted to attend your appointment at this time and you must self-isolate. Complete the self-assessment tool https://myhealth.alberta.ca/Journey/COVID-19/Pages/COVID-Self-Assessment.aspx at ahs.ca/covid to determine your need for COVID-19 testing.

If you answer “NO” to all of the above, you can proceed with testing. Please complete the following questions to the best of your ability. If you are unsure about any of the questions, please discuss with your Respiratory Therapist at the appointment.

*Close contact includes providing care, living with or otherwise having close prolonged contact (within 2 meters) while the person was ill, or contact with infectious bodily fluids (e.g. from a cough or sneeze) while not wearing recommended personal protective equipment. **Probable case is a person with clinical illness who had close contact to a lab-confirmed COVID-19 case, while not wearing appropriate personal protective equipment, OR a person with clinical illness who meets the COVID-19 exposure criteria, AND in whom laboratory diagnosis of COVID-19 is inconclusive. Clinical illness of a probable case is new onset/exacerbation of following symptoms: fever (over 38 degrees Celsius), cough, shortness of breath (SOB)/difficulty breathing, sore throat or runny nose. Exposure criteria for a probable case is a person who, in the 14 days before onset of illness: had any history of travel outside of Canada; OR had close contact with a confirmed or probable case of COVID-19; OR is a close contact of a traveler with acute respiratory illness who returned from outside Canada in the previous 14 days; OR had a laboratory exposure to biological material (e.g. primary clinical specimens, virus culture isolates) known to contain COVID-19.

PATIENT INFORMATION

Date:*

Address:

City/Postal Code:

Height:

Weight:

Occupation:

Phone (H):

Phone (Cell):

Email:

Emergency Contact:

Name of Next of Kin, relationship:

Phone:

Smoking History:

Do you currently smoke?

Yes
No

how many years they have been smoking for?

How many cigarettes per day:

Have you ever smoked?

Yes
No

Please indicate how many years you have smoked for and on average the quantity of cigarettes smoked per day:

How long ago did you quit:

Do you smoke/vape marijuana, or e-cigarette?

Yes
No

How long?

If applicable, when did you smoke your most recent cigarette/marijuan :

Please list ALL medications which you are taking. This includes medications from all of your doctors, chiropractors, herbologists and anything over the counter.

MEDICATION	DOSAGE	FREQUENCY

PARTICIPANT RIGHTS & CONSENT FORM

Dream Sleep Respiratory is committed to safeguarding the personal and health information entrusted to us. We manage this personal information in accordance with Alberta’s Health Information Act (HIA) and the Freedom of Information and Protection of Privacy Act (FOIP). Contact Information such as names, home address, home telephone numbers, work telephone numbers and e-mail addresses are collected and used for the following purposes:

To open and update patient files
Deliver requested services (Level 3 Sleep Assessment)
Contact patients about appointments
Provide referring physician with test results
Make appropriate referrals
Meet regulatory requirements.

Personal information is normally collected from the referring physician or directly from yourself, the patient as well as Netcare. We ask for consent to collect, use or disclose patient information in order to provide you with the services you have been referred for. You may choose not to provide consent for the use and disclosure of your personal information and we will respect your decision but you should be aware that we may not be able to provide you with the services for which you have been referred if we do not have the necessary information.

I consent to the collection, use and disclosure of my personal information as set out above. I understand that failure to consent may delay or prevent testing process.

Participants Rights and Responsibilities

As a participant, you have the right to expect the following from us:

The right to be fully informed about one’s medical condition;
The right to be advised of the available treatment options;
The right to be involved in treatment decisions;
The right to information on the qualifications and experience of the health professionals from who services are received;
The right to receive considerate, compassionate and respectful public health services;
The right to confidential communications with health professionals;
The right to have access to and copies of personal health records and to have them corrected, if necessary;
The right to have health records kept confidential and not used for any purpose other than public health services without written consent;
The right to designate a person to exercise rights on the patient’s behalf if the patient is not able to do so because of a physical or mental incapacity; and
The right to be informed of all rights and responsibilities under the bill and under other laws of Canada or a province with respect to public health services.
The right to be treated fairly and equally regardless of health condition, race, creed, personal beliefs, sexual orientation, or any other self-differentiating characteristic.

As a participant, you have the following responsibilities:

*

I the patient have read and agree to all the terms and agreements included in the form above.

I will provide to the best of my knowledge, complete and accurate information about my present health status and past medical history and to report any unexpected changes to appropriate Dream Sleep Respiratory Services Ltd. members.
I will notify the health care team members at Dream Sleep Respiratory Services Ltd. of ANY and ALL unusual signs, symptoms or problems I experience either at the facility or prior to entering the facility.

PATIENT CONSENT TO PROCEDURE

What is a Home Sleep Apnea Test?

A home sleep apnea test is a very simplified breathing monitor that tracks your breathing, oxygen levels, and breathing effort while worn. Home sleep apnea testing provides a physician accredited to interpret home sleep apnea tests by the College of Physicians and Surgeons of Alberta (CPSA), with the information he or she needs to diagnose obstructive sleep apnea. It allows you to sleep at home wearing equipment that collects information about how you breathe during sleep. You will set up the testing equipment yourself.

Why did my doctor order this test?

There are several sleep disorders, the most common being sleep apnea. People can have symptoms such as snoring, fatigue, excessive sleepiness, moodiness, impaired memory and concentration, and excessive urination or sweating at nighttime. The interpreting physician will use the results of your Home Sleep Apnea test to help to diagnose sleep apnea and to determine if further testing is required (eg Pulmonary Function Testing, Level 1 Sleep Testing). If you are diagnosed with sleep apnea, treatment options may include CPAP Therapy, an Oral Appliance or Lifestyle Modifications. Your Respiratory Therapist will discuss these options with you if they are recommended.

How should I prepare for this test?

Bring a list of your medications and allergies.
Be completely honest about your medical history and sleep symptoms.
Bring a translator if required.
Bring someone to help you set up the sleep apnea recorder if you feel you may have difficulty understanding the equipment.
Keep your normal nighttime routine to obtain the most reliable results.

How long will the test take?

The in-office portion of the test will last approximately 20-30 minutes. You will be asked a series of questions and then shown how to use the sleep apnea recorder at home. An instruction sheet will be provided. Please return the recorder the following business day.

Risks and Discomfort

The Respiratory Therapist will complete an assessment to ensure you are safe to proceed with testing. Please address any questions or concerns regarding your health with your Respiratory Therapist.

COVID 19 Considerations

Dream Sleep Respiratory follows all pre-screening and examination recommendations by Health Canada and the College of Physicians and Surgeons of Alberta to prevent the transmission risk of COVID 19. In the case of possible exposure to COVID 19, Dream Sleep Respiratory will inform Alberta Public Health. Alberta Health Services will then contact you to review COVID 19 testing and quarantine protocols. All necessary precautions have been taken to ensure the safety of our patients and staff. Physical barriers (i.e plastic coverings, plexiglass), additional PPE, and continuous cleaning measures are in place. The Remmers Sleep recorder uses sanitized and single use items such as filters and nosepieces. All surfaces are disinfected with appropriate cleaning agents between patients as per CPSA guidelines. Please be honest and accurate with the health history given to your Respiratory Therapist. If you have any questions or concerns, please convey them to us as soon as possible.

Results

Please be aware that Dream Sleep Respiratory LTD is not allowed to give you the results of the test. The test will be interpreted by a physician and you will be called with further instructions. A copy of the interpretation will be sent to your referring doctor within approximately one week of completing the test.

Date	Print Name	Signature