New Patient Paperwork | My Wordpress

Patient Information
First Name (Mr./Ms./Mrs./Dr)
Last Name
Home Phone
Work Phone
Cell Phone
The best time to contact me is:
- Morning
- Evening
- Mid-day
Contact Method
- Home Phone
- Cell Phone
Email Address
Date of Birth
Address
Street Address City State ZIP Code
Gender
- M
- F
Social Security Number SSN
Height - Feet
Height - Inches
Weight lbs
Marital Status
- Married
- Single
- Life Partner
- Minor
Spouse or Parent/Guardian (if minor) Name:
Emergency Contact - Name
Emergency Contact - Relationship
Emergency Contact - Phone
REFERRED BY
Employer Information
Employer
Phone
Fax
Employer Address
Street Address City State ZIP Code
Health Insurance Information
Patient’s Relationship to Primary Insured:
- Self
- Spouse
- Child
- Other
Name of Insured (First, MI, Last):
Insured Date of Birth
Ins Co:
Ins ID:
Group
Plan Name
Business Address
Street Address City State ZIP Code
Email
Phone
Fax
Secondary Insurance
DO YOU HAVE SECONDARY INSURANCE?
- Yes
- No
Relationship to Insured:
- Self
- Spouse
- Child
- Other
Name of Insured (First, MI, Last):
Insured Date of Birth
Ins Co:
Ins ID:
Plan Name
Address
Street Address City State ZIP Code
Phone
Fax
Email
Medical Contact
PRIMARY CARE DOCTOR - Name
PRIMARY CARE DOCTOR - Phone
ENT - Name
ENT - Phone
SLEEP DOCTOR - Name
SLEEP DOCTOR - Phone
DENTIST - Name
DENTIST - Phone
OTHER MD - Name
OTHER MD - Phone
OTHER MD 2 - Name
OTHER MD 2 - Phone
I certify this information is true, accurate, and complete to the best of my knowledge
Initial
Date
EPWORTH SLEEPINESS SCALE
0 = No chance of dozing
1 = Slight Chance of dozing
2 = Moderate Chance of dozing
3 = High Chance of dozing
Sitting and Reading
Watching TV
Sitting inactive in public place (theater)
As a car passenger for an hour without a break
Lying down in the afternoon to rest
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car while stopped at a traffic light
TOTAL
THORNTON SNORING SCALE
0 = Never
1 = 1 night/week
2 = 2-3 nights/week
3 = 4+ nights/week
My snoring affects my relationship with my partner
My snoring causes my partner to be irritable or tired
My snoring requires us to sleep in separate rooms
My snoring is loud
My snoring affects people when I am sleeping away from home
Total
Please list the main reason(s) you are seeking treatment for snoring or sleep apnea:
Do you have other complaints?
- Frequent snoring
- Excessive Day time 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
Subjective Signs and Symptoms
Rate your overall energy level
Rate your sleep quality
Have you been told you snore?
Rate the sound of your snoring
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?
Do you have a bed partner?
Do you sleep in the same room?
How many times per night does your bedtime partner notice you stop breathing?
Have you ever had a sleep study?
If YES, where and when?
Date (sleep study)
Have you tried CPAP?
Are you currently wearing a dental device?
If YES, 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 complaint s about CPAP?
- Mask leaks
- An inability to get the mask to fit properly
- Discomfort from the straps or headgear
- Decrease sleep quality or interrupted sleep from CPAP device
- Noise from the device disrupting sleep and/or bedtime partner's sleep
- CPAP restricts movement during sleep
- CPAP seems to be ineffective
- Device causes teeth or jaw problems
- A latex allergy
- Device causes claustrophobia or panic attacks
- An unconscious need to remove CPAP at night
- Caused GI/ stomach/ intestinal problems
- CPAP device irritated my nasal passages
- Inability to wear due to nasal problems
- Causes dry no se or dry mouth
- The device causes irritation due to air leaks
- Other
Other CPAP Complaints
Are you currently using CPAP?
Have you previously tried a dental device?
If YES, was it Over the Counter (OTC)?
Have you ever had surgery for .snoring or sleep apnea?
If YES, who fabricated it?
If applicable, please describe your previous dental device experience:
Was it fabricated by a dentist?
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-MEDICATlON - Have you been told you should receive pre-medication before dental procedures?
If YES, what med ication(s) and why do you require it?
ALLERGENS -- Please Iist everything you are allergic to (for example: aspirin, latex, penicillin, etc):
MEDICATIONS - Please Iist a Il medications you are currently taking:
MEDICAL HISTORY - Please list all medical l diagnoses and surgeries from birth untiI now (for example: heart attack, high blood pressure, asthma, stroke, hip replacement, HIV, diabetes, etc):
Dental History
How wouId you describe your dental health?
Have you ever had teeth extracted?
If YES, please describe
Do you wear removable partials?
Do you wear full dentures?
Have you ever worn braces (orthodontics)?
If YES, date completed:
Does your TMJ (jaw joint) click or pop?
Do you have pain in this joint?
Have you had TMJ (jaw joint) surgery?
Have you ever had gum problems?
If YES, have you ever had gum surgery?
Do you have dry mouth?
Have you ever had an injury to your head, face, neck, or mouth?
Are you planning to have dental work done in the near future?
Do you clench or grind your teeth?
If you answe red YES to any question above, please briefly describe your answer here:
Family History
Have genetic members of your family had:
Heart Disease?
High Blood Pressure?
Diabetes?
Have genetic members of your family been diagnosed or treated for a sleep disorder?
How often do you take sedatives 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?
If YES, how many packs per day?
Do you use chewing tobacco?
If YES, how many times per day?
PATIENT SIGNATURE
Patient or ·Guardian Signature

I certify that the information I have completed on these forms is true, accurate, and complete to the best of my knowledge.
Date

Date	Surgeon	Surgery

Patient Information

Employer Information

Health Insurance Information

Secondary Insurance

Medical Contact

I certify this information is true, accurate, and complete to the best of my knowledge

EPWORTH SLEEPINESS SCALE

THORNTON SNORING SCALE

Subjective Signs and Symptoms

If applicable, please describe your previous dental device experience:

Dental History

Family History

PATIENT SIGNATURE