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Sleep Apnea Patient Questionnaire
Contact Info
Name
First Name
Last Name
Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands (US)
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
State
ZIP Code
Phone
Email
Epworth Sleepiness Scale
Please Rate the Following:
0 = No Chance of Dozing | 1 = Slight Chance of Dozing | 2 = Moderate Chance of Dozing | 3 = High Chance of Dozing
Sitting and reading
*
0
1
2
3
Watching TV
*
0
1
2
3
Sitting inactive in a public place (theater)
*
0
1
2
3
As a car passenger for an hour without a break
*
0
1
2
3
Laying down in the afternoon to rest
*
0
1
2
3
Sitting and talking to someone
*
0
1
2
3
Sitting quietly after lunch without alcohol
*
0
1
2
3
In a car while stopped at a traffic light
*
0
1
2
3
Total
*
Thornton Snoring Scale
Please Rate the Following:
0 = Never | 1 = One night/week | 2 = 2-3 nights/week | 3 = 4+ nights/week
My snoring affects my relationship with my partner
*
0
1
2
3
My snoring causes my partner to be irritable or tired
*
0
1
2
3
My snoring requires us to sleep in separate rooms
*
0
1
2
3
My snoring is loud
*
0
1
2
3
My snoring affects people when I am sleeping away from home
*
0
1
2
3
Total
*
Please list the main reason(s) you are seeking treatment
*
Do you have any other complaints?
Frequent Snoring
Excessive Daytime Sleepiness (EDS)
Difficulty Falling Asleep
Waking Up Gasping/Choking
Morning Headaches
Neck or Facial Pain
I Have Been Told I Stop Breathing When I Sleep
Difficulty Maintaining Sleep
Choking While Sleeping
Feeling Unrefreshed in the Morning
Memory Problems
Impotence
Nasal Problems, Difficulty Breathing Through Nose
Irritability or Mood Swings
Other:
Other Value
Subjective Signs and Symptoms
Rate your overall energy level
*
1 (Low)
2
3
4
5
6
7
8
9
10 (Excellent)
Rate your sleep quality
*
1 (Low)
2
3
4
5
6
7
8
9
10 (Excellent)
Have you been told you snore?
*
YES
NO
Rate the sound of your snoring
*
1 (Quiet)
2
3
4
5
6
7
8
9
10 (Loud)
On average, how many times per night do you wake up?
*
On average, how many hours of sleep do you get per night?
*
How often do you awaken with headaches?
*
Never
Rarely
Sometimes
Often
Everyday
Do you have a bed partner?
*
YES
NO
Do you sleep in the same room?
YES
NO
How many times per night does your bedtime partner notice you stop breathing?
*
Several times per night
Once per night
Several times per week
Occasionally
Seldom
Never
Sleep Apnea Patient Questionnaire
Have you ever had a sleep study?
*
YES
NO
Please tell us where and when?
Have you tried CPAP?
*
YES
NO
Are you currently using CPAP?
*
YES
NO
How many nights per week do you wear it?
When you wear your CPAP, how many hours per night do you wear it?
If you use or have used CPAP, what are your chief complaints about CPAP?
Mask leaks
Can't get mask to fit properly
Straps or headgear cause discomfort
Decrease sleep quality or interrupted sleep
Noise from device disrupts sleeps and/or bedtime partner
Restricted movement during sleep
Seems to be ineffective
Causes teeth or jaw problems
Latex Allergy
Causes claustrophobia or panic attacks
Unconscious need to remove device at night
Caused GI/stomach/intestinal problems
Inability to wear because of nasal problems
Causes dry nose or mouth
Causes irritation due to air leaks
Other:
Other Value
Are you currently wearing a dental device?
*
YES
NO
Have you previously tried a dental device?
*
YES
NO
Was it Over the Counter (OTC)?
YES
NO
Was it fabricated by a dentist?
YES
NO
Who fabricated it?
If applicable, please describe your previous dental device experience:
Have you ever had surgery for snoring or sleep apnea?
*
YES
NO
Please list any nose, palatal, throat, tongue, or jaw surgeries you have had (Date, Surgeon, Surgery):
Please comment about any other therapy attempts (weight loss, gastric bypass, etc.) and how each impacted your snoring and apnea and sleep quality:
PRE-MEDICATION - Have you been told you should receive pre-medication before dental procedures?
*
YES
NO
What medication(s) and why do you require it?
ALLERGENS - Please list everything you are allergic to (for example: aspirin, latex, penicillin, etc):
*
MEDICATIONS - Please list all medications you are currently taking:
*
MEDICAL HISTORY - Please list all medical diagnoses and surgeries from birth until now (for example: heart attack, high blood pressure, asthma, stroke, hip replacement, HIV, diabetes, etc):
*
Dental History
How would you describe your dental health?
*
Excellent
Good
Fair
Poor
Have you ever had teeth extracted?
*
YES
NO
Please describe:
Do you wear removable partials?
*
YES
NO
Have you ever worn braces (orthodontics)?
*
YES
NO
Date completed?
Does your TMJ (jaw joint) click or pop?
*
YES
NO
Do you have pain in this joint?
YES
NO
Have you had TMJ (jaw joint) surgery?
*
YES
NO
Have you ever had gum surgery?
YES
NO
Do you have dry mouth?
*
YES
NO
Have you ever had an injury to your head, face, neck, or mouth?
*
YES
NO
Are you planning to have dental work done in the near future?
*
YES
NO
Do you clench or grind your teeth?
*
YES
NO
If you answered YES to any question above, please briefly describe your answer here:
Family History
Have genetic members of your family had:
Heart Disease?
*
YES
NO
High Blood Pressure?
*
YES
NO
Diabetes?
*
YES
NO
Have genetic members of your family been diagnosed or treated for a sleep disorder?
*
YES
NO
How often do you consume alcohol within 2-3 hours of bedtime?
*
Daily
Occasionally
Rarely/Never
How often do you take sedatives within 2-3 hours of bedtime?
*
Daily
Occasionally
Rarely/Never
How often do you consume caffeine within 2-3 hours of bedtime?
*
Daily
Occasionally
Rarely/Never
Do you smoke?
*
YES
NO
How many packs per day?
Do you use chewing tobacco?
YES
NO
How many times per day?
Patient Signature
I certify that the information I have completed on these forms is true, accurate, and complete to the best of my knowledge.
Patient or Guardian Signature
*
Date
*
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