Sleep Apnea QuestionnaireThis questionnaire is designed to help us understand your chief complaints of sleep apnea, as well as get to know your sleep apnea history. Please take time to fill this out to your best knowledge. Step 1 of 4 25% Patient Name* First Last Height*Weight*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Home PhoneCell Phone*Email* Preferred Sound Sleep Medical Location*North OgdenProvoSandyLaytonMurrayAmerican ForkAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Primary Care PhysicianPrimary Care Physician Phone NumberDentistDentist Phone NumberSleep SpecialistSleep Specialist Phone NumberInsurance InformationPrimary InsurancePrimary Insurance Company*Primary Policy Holder Name*Primary Policy Holder Date of Birth* Date Format: MM slash DD slash YYYY Primary Policy Holder ID#*Primary Group #*Secondary InsuranceSecondary Insurance CompanySecondary Policy Holder NameSecondary Policy Holder Date of Birth Date Format: MM slash DD slash YYYY Secondary Policy Holder ID#Secondary Group #Emergency Contact InformationEmergency Contact Name* First Last Emergency Contact Phone*Emergency Contact Relationship*Communication Preference:Your Privacy is important to us. Please let us know how we can contact you.May we contact you via email for treatment follow up?*YesNoMay we leave message on your answering machine or phone?*YesNoIs there anyone, other than yourself, with whom we may discuss your appointment/treatments?*YesNoPlease list name & phone number:*I authorize Sound Sleep Medical LLC to release any medical information requested by insurance companies, and to representatives of local, state, and federal agencies, if applicable. I also authorize Sound Sleep Medical LLC to request any medical records needed regarding my sleep apnea history.Patient Signature:*Please enter your full name. This e-signature will be considered equal to a physical (pen & paper) signature.Date* Date Format: MM slash DD slash YYYY Sleep Health QuestionnairePlease Check Any Symptoms Below That Apply to You* Diagnosed with Sleep Apnea Frequent/Heavy Snoring Morning Jaw Pain Told I Stop Breathing During Sleep Morning Headaches Diabetes Depression Nighttime Choking Spells Gasping When Waking Up Fatigue High Blood Pressure Memory Loss Stroke Heart Disease Other Please list:*Do any members of your family have, or have had, sleep apnea?*YesNoHave you ever had oral or nasal surgery?*YesNoHave you ever had a sleep study?*YesNoWhen was it done?*Do you currently use a CPAP machine at night?*YesNoHow long have you been using it?*Are you using it each night, all night?*Who prescribed the CPAP machine?*Why?*EPWORTH SCALE ASSESSMENTPlease read through the situations below and answer how likely you are to doze off. Use the scale below to choose the most appropriate number for each situation. 0 = No Chance of Dozing< /td> 1 = Slight Chance of Dozing 2 = Moderate Chance of Dozing 3 = High Chance of Dozing Dozing off while sitting and reading?Please enter a number from 0 to 3.Dozing off while watching TV?Please enter a number from 0 to 3.Dozing off while sitting in a public place? (meeting, theatre, etc.)Please enter a number from 0 to 3.Dozing off while riding as a passenger in a car?Please enter a number from 0 to 3.Dozing off while sitting and talking to someone?Please enter a number from 0 to 3.Dozing off while sitting quietly after lunch?Please enter a number from 0 to 3.Dozing off while driving a care and stopped for a few minutes in traffic?Please enter a number from 0 to 3.Your TotalResults: If your total is 0 - 9: This suggests you may not be suffering from excessive daytime sleepiness.If your total is 9+: This suggests you may need further evaluation to determine the cause of your daytime sleepiness, and whether you may have an underlying sleep disorder.Dental Health QuestionnaireDentist Name First Last Dentist PhonePatient Dental History:Date of Last Dental Cleaning* Date Format: MM slash DD slash YYYY Do you get your teeth cleaned at least once a year?*YesNoDate of Last Dental Examination* Date Format: MM slash DD slash YYYY Do you have dental work that needs to be done?*YesNoWhat dental work is needed?*Have you had orthodontic treatment (braces, invisalign, etc.)?*YesNoAt what age?*Patient Questionnaire:Do you have less than 10 teeth on your top jaw?*YesNoHow many do you have?*Do you have less than 10 teeth on your lower jaw?*YesNoHow many do you have?*Have you been told you have gum disease? (periodontal disease)*YesNoDo your gums bleed when you brush or floss?*YesNoAre your gums infected?*YesNoDo your teeth hurt?*YesNoDo you have any crowns?*YesNoDo you have any fillings?*YesNoDo you have any broken teeth?*YesNoHave you been told that you have TMJ (TMD) or jaw problems?*YesNoDoes your jaw ever hurt?*YesNoHow often?*Does your jaw pop or make noise?*YesNoHow often?*Does your jaw hurt when you chew?*YesNoHow often?*Does your jaw ever lock open?*YesNoHow often?*Is it hard or painful to open your mouth wide?*YesNoDo you get frequent headaches?*YesNoHow often?*Do you have dentures or removable partials?*YesNoDo you have any loose teeth?*YesNo CPAP Intolerance AffidavitI have not tried a CPAP machine. I would prefer the use of an oral appliance.I have not tried a CPAP machine. I would prefer the use of an oral appliance.It has been recommended by my sleep physician/primary care doctor that I try a CPAP machine to manage my Obstructive Sleep Apnea ("OSA"). I find the CPAP machine intolerable to use on a regular basis due to the following reasons:Excessive sleepiness persists with CPAP machineYesNoThe CPAP mask leaksYesNoI am unable to sleep with the CPAP equipment in placeYesNoI unconsciously remove the CPAP machine at nightYesNoThe noise from the CPAP disturbs my sleep/my bed partner's sleepYesNoCPAP is not effective in eliminating my sleep apnea symptomsYesNoI cannot find a comfortable maskYesNoI am claustrophobic while using CPAPYesNoI am allergic to the CPAP materialsYesNoI have developed sinus infections while using CPAPYesNoDue to my inability or refusal to tolerate CPAP and my need to effectively treat the symptoms of my OSA, I wish to attempt an alternative therapy. The 2006 parameters from the AASM (American Academy of Sleep Medicine) state that oral appliances are an effective treatment for OSA. I wish to utilize oral appliance therapy to treat my obstructive sleep apnea. Patient Signature:*Please enter your full name. This e-signature will be considered equal to a physical (pen & paper) signature.Patient Name*Date* Date Format: MM slash DD slash YYYY Physician Acknowledgement x__________________________________________________
