Sleep Apnea Questionnaire This 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 5 20% Name* First Last Home PhoneCell Phone*Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Refered ByFamily Physician Name:Family Physician Phone Number:Please check each box below if the condition applies to you. I have been diagnosed with Sleep Apnea Frequent heavy snoring CPAP intolerance Daytime drowsiness I'm told I "stop breathing" while sleeping Morning headaches TMJ issues Jaw Pain Nighttime choking spells Gasping when waking up Sleep Center EvaluationHave you ever had a sleep study done?*YesNoWhat type of study was done?Overnight in a hospitalAt homeSleep Center Name:Describe the results of the study:Medical HistoryPlease briefly describe your history with each of the following. Leave the description blank if you have no history with a given condition.FatigueMemory LossDepressionHigh Blood PressureHeart DiseaseDiabetesLung/Breathing problemsPlease select all that apply: I have a family history of Sleep Apnea I have a pacemaker I use oxygen I currently use a CPAP machine If you are using a CPAP, how long have you been using it? Excessive Daytime Sleepiness Evaluation (Epworth Scale)Please read through the situations below and see how likely you are to doze off. Even if you have not done some of these things recently try to think how they would have affected you. Use the scale below to choose the most appropriate number for each situation. 0 = No chance of dozing while performing the task 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozing Sitting and ReadingPlease enter a value between 0 and 3.Watching TVPlease enter a value between 0 and 3.Sitting in a public place (meeting, theater, etc.)Please enter a value between 0 and 3.Riding as a passenger in a carPlease enter a value between 0 and 3.Lying down to rest in the afternoonPlease enter a value between 0 and 3.Sitting and talking with someonePlease enter a value between 0 and 3.Sitting quietly after lunchPlease enter a value between 0 and 3.Driving a car while stopped for a few minutes in trafficPlease enter a value between 0 and 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. Privacy Communication FormWe comply with the Health information privacy act, HIPAA. We want to make sure we guard your privacy according to you standards.Please answer the following questions:May we contact you via email for treatment follow ups?*YesNoMay we leave messages on your answering machine?*YesNoIs there anyone else (spouse, children, etc.) with whom you would like us to discuss your appointments/treatments?*YesNoIf yes, please list:You must inform us in writing of any changes to this information. This record takes effect on the date signed below and will be kept in your paper chart.Patient Signature:*Please enter your full name. This e-signature will be considered equal to a physical (pen & paper) signature.Date* Release of InformationI authorize Sound Sleep Medical LLC to release any medical information requested by representatives of local, state, federal agencies and insurance companies. 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* CPAP Intolerance AffidavitIt has been recommended by my sleep physician/primary care doctor that i try a CPAP machine to manage my Obstructive Sleep Apnea. I find the CPAP machine intolerable to use on a regular basis due to the following reasons:(Select all that apply) The mask leaks I am unable to sleep with the equipment in place I unconsciously remove the CPAP machine at night The noise from the CPAP disturbs my sleep/my bed partners sleep CPAP machine does not seem to be effective in eliminating my Sleep Apnea symptoms I cannot find a comfortable mask I am claustrophobic I am allergic to the the materials I develop sinus infections Other If you selected 'Other' please specify:Add any reasons that are not in the list above. Due to my inability 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 the 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.Date*
