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Patient Information

Patient Name


Date of Birth / /

Sex: Male Female

Height: Feet Inches

Weight: lbs.


Summary of Sleep Complaints

Chief Complaint
Snoring:
Sleepiness/Fatigue:
Other:

Snoring
Do you snore no matter what position you are lying in? Yes No Do Not Know
Do you snore every night? Yes No Do Not Know
Is your snoring interrupted by pauses and/or choking sounds? Yes No Do Not Know
Has your sleep mate ever commented on your snoring? Yes No Do Not Know
On a scale of 1-10 with 10 being loudest, how loud is your snoring:
Other comments:

Sleepiness/Fatigue
How would you describe yourself? (Check all that apply)
Fatigued Sleepy Tired Other
What tasks or activities have you eliminated or find difficulty in completing?
What is your energy level on a scale of 1-10? 1 being no energy and 10 being very high energy .
Other comments:
Sleep
Average time you go to sleep? wake up?
How long does it take you to fall asleep? <1 min <5 min <15 min >15 min
Is it difficult to fall back asleep if you awake during the night? Yes No
How often do you awake during the night (bathroom, clock, noises, etc…)? time(s) a night
Rate your quality of sleep on a scale of 1-10? 1 being very poor and 10 being excellent.
Do you take any medications or other products for sleeping? Yes No
If yes, please list:
Do you take naps routinely ? Yes No
Other comments:
Nasal conditions
Are you able to breathe easily through your nose? Yes No
Are you nasally congested during the day? Yes No
Is your nasal congestion worse at night? Yes No
Do you experience nasal allergies resulting in intermittent nasal blockage? Yes No
Medications for allergies? None Shots Nasal Spray
Do you breathe through your mouth? Never Most of the Time At Night
Do you wake with a sore throat? Yes No
Do you wake with a dry mouth? Yes No
Other problems:
Other conditions or symptoms that may be related
Asthma Hoarseness
Chronic sinus problems Use of nasal sprays
COPD Insomnia
Depression Impotence
Diabetes Memory loss
Emphysema Migraines
Fibromyalgia Reflux
Stroke Recent weight gain
Headache Swelling in extremities
High Blood Pressure Teeth grinding
High Cholesterol Thyroid disorder
History of evaluation or treatment of sleep disordered breathing
Have you ever been evaluated or treated for your snoring or sleep apnea? Yes No
If yes, please continue answering questions 2-19

Overnight sleep study (PSG)? Yes No   3. Date: / /
Name of physician or center:
Address:
Diagnosis: Don't Know Simple Snoring Mild Apnea Moderate Apnea Severe Apnea Other
Treatment options or recommendations: Weight Loss Surgery CPAP Oral Appliance Other
Weight loss attempted? Yes No Amount Lost: Amount Regained:
Surgical Treatment? Yes No   Date: / /
Type of Surgery: UPPP(palatal surgery) LAUP(laser palatal surgery) Nasal Surgery
  Somnoplasty Pillar Jaw surgery Bariactric Other
Results of Surgery: Reduced sleep apnea and snoring permanently
  Reduced or eliminated sleep apnea and/or snoring initially but symptoms have returned
  I gained no benefit from the surgery
Symptoms caused by surgery: Having fluid or food pass into your nose when you swallow
  A change in how your voice sounds Pain in the throat when swallowing
  Coughing Other
CPAP: I was offered a trial of CPAP but decided to try other options first
  I tried CPAP during a sleep study but could not wear it
  I am presently wearing a CPAP
  If yes, Number of days per week Number of hours per day
  Date started using CPAP Type of mask
  How do you feel after wearing the mask? I feel refreshed and well rested every morning
    It helps, but I still feel tired or unrefreshed
    I feel no better with the CPAP
    I tried wearing a CPAP but discontinued.
Symptoms with CPAP: runny nose
  stuffed, congested, blocked nose
  excessive dryness of the nose or throat passages especially on awakening
  soreness in the nose or throat passages
  headaches
  eye irritation
  ear pain
  waking up frequently during the night
  difficulty returning to sleep if awakened
  air leakage from the mask
  discomfort from the mask
  marks or rash on the face
  allergy to the mask
  complaints from the bed partner about CPAP
  claustrophobia
  unconscious removal of the mask
  other
Dentist:
Address:
Type of appliance: TAP Herbst Klearway PM Positioner Other
I am presently wearing an oral appliance : Yes No
  If yes, number of days per week Number of hours per day
  Date started using  
  Symptoms with an oral appliance: Pain or aching in the jaw joint
    aching in the teeth that lasts more than one hour
    excessive salivation
    difficulty in chewing
   

other

Past History

Medical History
AIDS/HIV Heart Disease
Anemia Hepatitis
Arthritis Kidney Disease
Bladder Disease Liver Disease
Bleeding Disorders Mitral Valve Prolapse
Breathing Problems Low Blood Pressure
Cancer Prostate Problems
Chronic fatigue Pregnant
Dizziness Shortness of Breath 
Epilepsy Tuberculosis
Glaucoma Ulcers
Hearing Loss  
Have you been under the care of a physician in the last year for anything other than a routine physical? Yes No
If yes, please explain
List any major illnesses in the past five years 
Dental History
Have you ever had orthodontic treatment (braces)? Yes No
Have teeth been removed for orthodontic reasons? Yes No
Are your teeth sensitive to hot or cold? Yes No
Are you aware of a tired feeling your face? Yes No
Do you have ringing or pain in your ears? Yes No
Do you clench or grind your teeth? Yes No
Do you have frequent headaches? Yes No
Do you have pain around your ears, eyes, head, or neck? Yes No
Have you been diagnosed with a temporomandibular disorder (TMJ)? Yes No
Do you have any loose teeth? Yes No
Do you have any dental prosthesis (crowns, dentures)? Yes No
Do you have any dental problems? Yes No
If yes, please explain
Surgical History
List any surgical procedures including childhood surgeries:
 
Medications
  It is helpful for your physician to know about the types of medications you are currently taking.  Because many people cannot recall details of the prescriptions or over-the-counter medications at the doctor’s office, complete this form to bring to your appointment. 
 
Medication Name Why are you taking this medication Dosage How long have you been taking this medication
Medication Allergies
  Please list 
 
Family History
Father: Alive Deceased Cause of death
  History of Snoring Sleep Apnea Heart Disease High Blood Pressure Diabetes Other
Mother: Alive Deceased Cause of death
  History of Snoring Sleep Apnea Heart Disease High Blood Pressure Diabetes Other
Alive Deceased Cause of death
  History of Snoring Sleep Apnea Heart Disease High Blood Pressure Diabetes Other
Alive Deceased Cause of death
  History of Snoring Sleep Apnea Heart Disease High Blood Pressure Diabetes Other
Alive Deceased Cause of death
  History of Snoring Sleep Apnea Heart Disease High Blood Pressure Diabetes Other
Social History
Are you married or divorced? Married Divorced
How many children do you have?
What is your occupation?
What is your education?
What is your alcohol consumption? Never Occasionally Daily Number of beverages per day
What is your caffeine consumption? Never Occasionally Daily Number of beverages per day
Do you smoke? Never Smoke Smoked for and quit in I presently smoke a day
Do you use recreational drugs? Never Occasionally Daily Drugs used:


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