North Collier Sleep Diagnostic Center
Jose R. Marquina, M.D., F.C.C.P.
1855 Veterans Park Dr
Suite 302
Naples, FL 34109

239-592-LUNG (5864)

       

Please print and fill out the following two forms prior to your first appointment.
 

New Patient Registration Form

This is your demographics and contact information form, including insurance information.

 

 

 

Medical Records Release

This authorizes us to retrieve and share medical information with the appropriate entities.

 

 

 

Important New Patient Information

This informational document answers many of the common questions new patients ask.

 

 

   
You may be asked to fill out the following forms to assist us
in accurately diagnosing your specific sleep disorder.
   

Sleep Survey

A comprehensive questionnaire to help determine if a sleep disorder is present. It is important for us to examine all aspects of your health in order to properly diagnose your sleep disturbance. This will require approximately twenty minutes to complete.

 

 

Epworth Sleepiness Scale

The Epworth Sleepiness Scale is used to determine the level of daytime sleepiness. A score of 10 or more is considered sleepy. A score of 18 or more is very sleepy. If you score 10 or more on this test, you should consider whether you are obtaining adequate sleep, need to improve your sleep hygiene and/or need to see a sleep specialist. These issues should be discussed with Dr Marquina at your appointment.

 

 

Sleep Log

If you feel sleepier than you would like to be, you may be significantly sleep deprived and sleepiness may be getting the best of you.  Try keeping a sleep log for a week or two and take a careful look at your sleep schedule and behaviors. This will enable us to more accurately diagnose sleep disorders and improve sleep hygiene.

 

 

 

 

 

       
   
Copyright © 2008 North Collier Sleep Diagnostic Center