Salt Lake City Questionnaire

"*" indicates required fields

Step 1 of 3

33%

Patient Name*

First Last

Height*

Weight*

Email*

Date of Birth*

Home Phone

Cell Phone*

Preferred Sound Sleep Medical Location*

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Care Physician

Primary Care Physician Phone Number

Sleep Physician

Sleep Physician Phone Number

Dentist

Dentist Phone Number

Insurance Information

Primary Insurance Company*

Primary Policy Holder Name*

Primary Policy Holder Date of Birth*

MM slash DD slash YYYY

Primary Group #*

Primary Policy Holder ID#*

Secondary Insurance Company*

Secondary Policy Holder Name*

Secondary Policy Holder Date of Birth*

MM slash DD slash YYYY

Secondary Group #*

Secondary Policy Holder ID#*

Hidden

Secondary Insurance Company

Hidden

Secondary Policy Holder Name

Hidden

Secondary Policy Holder Date of Birth

MM slash DD slash YYYY

Hidden

Secondary Policy Holder ID#

Hidden

Secondary Group #

Emergency Contact Information

Emergency Contact Name*

First Last

Emergency Contact Phone*

Emergency Contact Relationship*

Have you ever had a sleep test?*

Yes

If yes, when was your last sleep test? Who provided the test?*

Are you currently taking any medications?*

Yes

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

May we leave message on your answering machine or phone?*

Yes

Is there anyone, other than yourself, with whom we may discuss your appointment/treatments?*

Yes

Please list name & phone number:*

Dental Health Questionnaire

Dentist Name

First Last

Dentist Phone

Patient Dental History:

Date of Last Dental Cleaning:

MM slash DD slash YYYY

Do you get your teeth cleaned at least once a year?*

Yes

Date of Last Dental Examination:

MM slash DD slash YYYY

Do you have dental work that needs to be done?*

Yes

If yes, what dental work is needed?*

Have you had orthodontic treatment (braces, Invisalign, etc.)?*

Yes

If yes, at what age?*

Patient Questionnaire (please check yes or no):

Hidden

Do you have less than 10 teeth on your top jaw?*

Yes

Hidden

If yes, how many do you have?

Are you missing more than four teeth on either your upper or lower jaw?

Yes

Hidden

Do you have less than 10 teeth on your lower jaw?*

Yes

Hidden

If yes, how many do you have?

Have you been told you have gum disease? (periodontal disease)*

Yes

Do your gums bleed when you brush or floss?*

Yes

Are your gums infected?*

Yes

Do your teeth hurt?*

Yes

Do you have any crowns?*

Yes

Do you have any fillings?*

Yes

Do you have any broken teeth?*

Yes

Do you have dentures or removable partials?

Yes

Do you have any loose teeth?

Yes

Have you been told that you have TMJ (TMD) or jaw problems?*

Yes

Does your jaw ever hurt?*

Yes

If yes, how often?

Hidden

If yes, how often?

Does your jaw pop or make noise?*

Yes

Does your jaw hurt when you chew?*

Yes

Hidden

If yes, how often?

Does your jaw ever lock open?*

Yes

If yes, how often?

Is it hard or painful to open your mouth wide?*

Yes

If yes, how often?

Do you get frequent headaches?*

Yes

Hidden

If yes, how often?

Hidden

Do you have dentures or removable partials?*

Yes

Hidden

Do you have any loose teeth?*

Yes

Sleep Health Questionnaire

Please 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 above

Physician Name

First Last

Treatment Date

MM slash DD slash YYYY

EPWORTH SCALE ASSESSMENT

Please 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?