Insurance Information

Emergency Contact Information

Communication Preference:

Results:
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.

Patient Dental History:

Patient Questionnaire:

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:

Due 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.