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. "*" indicates required fields Step 1 of 4 25% Patient Name* First Last Height* Weight* Email* Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Home PhoneCell Phone*Preferred Sound Sleep Medical Location*Please select a locationNorth OgdenProvoSandyLaytonAmerican ForkSalt Lake CityMurrayMailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Primary Care Physician Primary Care Physician Phone NumberHiddenDentist HiddenDentist Phone NumberSleep Physician Sleep Physician Phone NumberInsurance InformationPrimary Insurance Company* Primary Policy Holder Name* Primary Policy Holder Date of Birth* MM slash DD slash YYYY Primary Policy Holder ID#* Primary Group #* HiddenSecondary Insurance Company HiddenSecondary Policy Holder Name HiddenSecondary Policy Holder Date of Birth MM slash DD slash YYYY HiddenSecondary Policy Holder ID# HiddenSecondary Group # Emergency Contact InformationEmergency Contact Name* First Last Emergency Contact Phone*Emergency Contact Relationship* Have you ever had a sleep test?* Yes No If yes, when was your last sleep test? Who provided the test?*Are you currently taking any medications?* Yes No If yes, please list medication and dosage:*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?* Yes No May we leave message on your answering machine or phone?* Yes No Is there anyone, other than yourself, with whom we may discuss your appointment/treatments?* Yes No Please list name & phone number:* Dental Health QuestionnaireDentist Name First Last Dentist PhonePatient Dental History:Date of Last Dental Cleaning: MM slash DD slash YYYY Do you get your teeth cleaned at least once a year?* Yes No Date of Last Dental Examination: MM slash DD slash YYYY Do you have dental work that needs to be done?* Yes No If yes, what dental work is needed?* Have you had orthodontic treatment (braces, Invisalign, etc.)?* Yes No If yes, at what age?* Patient Questionnaire (please check yes or no):HiddenDo you have less than 10 teeth on your top jaw?* Yes No HiddenIf yes, how many do you have? Are you missing more than four teeth on either your upper or lower jaw? Yes No HiddenDo you have less than 10 teeth on your lower jaw?* Yes No HiddenIf yes, how many do you have? Have you been told you have gum disease? (periodontal disease)* Yes No Do your gums bleed when you brush or floss?* Yes No Are your gums infected?* Yes No Do your teeth hurt?* Yes No Do you have any crowns?* Yes No Do you have any fillings?* Yes No Do you have any broken teeth?* Yes No Do you have dentures or removable partials? Yes No Do you have any loose teeth? Yes No Have you been told that you have TMJ (TMD) or jaw problems?* Yes No Does your jaw ever hurt?* Yes No If yes, how often? HiddenIf yes, how often? Does your jaw pop or make noise?* Yes No Does your jaw hurt when you chew?* Yes No HiddenIf yes, how often? Does your jaw ever lock open?* Yes No If yes, how often? Is it hard or painful to open your mouth wide?* Yes No If yes, how often? Do you get frequent headaches?* Yes No HiddenIf yes, how often? HiddenDo you have dentures or removable partials?* Yes No HiddenDo you have any loose teeth?* Yes No Sleep Health QuestionnairePlease Check Any Symptoms Below That Apply to You* Anxiety Facial Surgery or Trauma Teeth Grinding Morning Jaw Pain Morning Headaches Diabetes Depression Oral or Nasal Surgery Ehlers-Danlos Syndrome (elastic skin) Hay Fever/Sinus Infections Fatigue Memory Loss Claustrophobia Stroke History of Allergies Excessive Daytime Sleepiness Impaired Cognition Chronic Bloody Nose Frequent/Heavy Snoring Nighttime Choking Spells Air/Bleeding in Chest High Blood Pressure Collapsed Lung Low Blood Pressure Heart Disease Dry Mouth Emphysema (Shortness of Breath) Told I Stop Breathing During Sleep Respiratory Failure Lack of Concentration Other (Please Specify): If you have received treatment for any checked abovePhysician Name First Last Treatment Date MM slash DD slash YYYY 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 car and stopped for a few minutes in traffic?Please enter a number from 0 to 3.Dozing off when lying down in the afternoon, when circumstances permit?Please enter a number from 0 to 3.Your TotalRelease of Information: 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 MM slash DD slash YYYY Patient Name First Last CPAP Intolerance AffidavitI cannot tolerate CPAP machine due to the reasons outlined below, or I have a history of these outlined below which would make CPAP use difficult. Confirm HiddenI 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:The American Academy of Sleep Medicine has indicated that oral appliances are an effective treatment for obstructive sleep apnea. However, some insurance companies or physicians require the trial of CPAP therapy to manage obstructive sleep apnea prior to the use of other therapies. Please answer accordingly: I have tried to use CPAP. I did not tolerate CPAP therapy on a regular basis for the reasons below. I have not tried CPAP. I will not tolerate CPAP therapy on a regular basis for the reasons below. HiddenIt 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: I am claustrophobic I am allergic to latex I have developed sinus infections previously or while using CPAP I have anxiety which would make CPAP use difficult I have restricted movement during sleep I am a light sleeper Excessive sleepiness persists with CPAP machine. The CPAP mask leaks I am unable to sleep with the CPAP equipment in place I unconsciously remove the CPAP machine at night The noise from the CPAP disturbs my sleep/my bed partner’s sleep CPAP is not effective in eliminating my sleep apnea symptoms I have tried multiple masks (e.g. full face, nose, nasal pillow, etc.) HiddenHave you discussed these concerns with your physician? Yes No HiddenIf yes, who did you discuss it with? Physician Name: HiddenDate MM slash DD slash YYYY HiddenDo you currently use a CPAP machine at night? Yes No HiddenIf yes, how long have you been using it? HiddenIf yes, are you using it each night, all night? HiddenIf no, why? HiddenWho prescribed the CPAP machine? Due to my inability or refusal to tolerate CPAP and my need to effectively treat the symptoms of my obstructive sleep apnea, 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* MM slash DD slash YYYY
