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FOR MORE INFORMATION CALL (888) 844-9845

SLEEP ASSESSMENT
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Sleep Apnea Questionnaire 2019

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%


  • Please check each box below if the condition applies to you.
  • Sleep Center Evaluation

  • Date Format: MM slash DD slash YYYY
  • Medical History

  • Please briefly describe your history with each of the following. Leave the description blank if you have no history with a given condition.

  • 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
  • Please enter a number from 0 to 3.
  • Please enter a number from 0 to 3.
  • Please enter a number from 0 to 3.
  • Please enter a number from 0 to 3.
  • Please enter a number from 0 to 3.
  • Please enter a number from 0 to 3.
  • Please enter a number from 0 to 3.
  • Please enter a number from 0 to 3.
  • 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.

  • Privacy Communication Form

    We 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:
  • 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.

  • Please enter your full name. This e-signature will be considered equal to a physical (pen & paper) signature.
  • Date Format: MM slash DD slash YYYY
  • Release of Information

  • I 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.
  • Please enter your full name. This e-signature will be considered equal to a physical (pen & paper) signature.
  • Date Format: MM slash DD slash YYYY
  • CPAP Intolerance Affidavit

  • It 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:

  • 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.

  • Please enter your full name. This e-signature will be considered equal to a physical (pen & paper) signature.
  • Date Format: MM slash DD slash YYYY
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(888) 844-9845
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North Ogden, UT
1075 North Washington Blvd.
Ogden, UT 84404
(801) 528-4889

Provo, UT
3216 N University Ave.
Provo, UT 84604
(801) 615-2674

Lehi, UT
216 E Main St., #1
Lehi, UT 84043
(801) 800-8106

Sandy, UT
8941 South 700 East Suite 204
Sandy, UT 84070
(801) 937-4719

St. George, UT
640 East 700 South, Building 2
St. George, UT 84770
(435) 275-4624

Layton, UT
365 W 1550 N, Suite E
Layton, UT 84041
(801) 528-4912

Murray, UT
310 E. 4500 S., Suite 110
Murray, UT 84107
(801) 685-3430

Nampa, ID
210 W Georgia Ave #100
Nampa, ID 83686
(208) 475-4350

Boise, ID
1070 N. Curtis Road, Suite 110
Boise, ID 83706
(208) 908-6278

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info@soundsleepmedical.com
(888) 844-9845
  • Treatments
  • About
  • News
  • Contact Us
© Sound Sleep Medical, Inc. All rights reserved. Website Designed by AuDSEO
  • About
    • Meet Our Dentists
  • Testimonials
  • Sleep Apnea
    • Myths & Facts
    • Treatments
  • Oral Appliance
  • Blog
  • Locations
    • North Ogden, UT
    • Provo, UT
    • Sandy, UT
    • St. George, UT
    • Layton, UT
    • Murray, UT
    • Lehi, UT
    • Nampa, ID
    • Boise, ID

5 QUESTION SURVEY

Simply answer the following 5 questions Yes or No to see if you qualify.
If you have any questions or concerns please call: 801-762-6888.

Step 1 of 5

20%
  • Congratulations!!!

    You qualify for a free sleep assessment to try this revolutionary new sleep apnea device. Please provide us your contact info, so we can schedule your free assessment.
  • Please enter your 5 digit zip code

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