Patient Questionaire - IMO Sleep Solutions

Welcome

First Name

Last Name

-> EPWORTH SLEEPINESS SCALE

Please rate the following based on this 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 a 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

-> THORTON SNORING SCALE

Please rate the following based on this 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:

Other

-> Subjective Signs and Symptoms

Rate your overall energy level (1 being low, 10 being excellent)

Rate your sleep quality (1 being low, 10 being excellent)

Have you ever been told you snore

Rate the sound of your snoring (1 being quiet, 10 being 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 wake up with headaches?

Do you have a bed partner

Do you sleep in the same room

Yes No

How many times per night does your bedtime partner notice you stop breathing

Have you ever had a sleep study?

Yes No

If so where?

and when?

Have you tried CPAP?

Yes No

Are you currently using CPAP?

Yes No

If yes, how many nights per week do you use it?

When you wear your CPAP, how many hours per night do you wear it?

Other:

Are you currently wearing a dental device?

Yes No

Have you previously tried a dental device?

Yes No

If YES, was it Over the Counter (OTC)?

Yes No

Was it fabricated by dentist

Yes No

If applicable, please describe your previous dental device experience:

Have you ever had a 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

If yes, what medication(s) and why do you require it?

ALLERGENS -- Please list everything you are allergic to (for example: asprin, latex, penicillin, etc)

Medications -- Please list all medication 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?

Have you ever had teeth extracted?

Yes No

Do you wear removable partials?

Yes No

Do you wear full dentures?

Yes No

Have you ever worn braces (orthodontics)?

Yes No

If Yes, 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 problems

Yes No

If Yes, 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 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?

How often do you take sedatives within 2-3 hours of bedtime?

How often do you consume caffeine within 2-3 hours of bedtime?

Do you use chewing tobacco? If yes, how many times a day?

Yes No

Do you smoke? If yes, how many packs a day?

Yes No

Welcome

-> EPWORTH SLEEPINESS SCALE

-> THORTON SNORING SCALE

-> Subjective Signs and Symptoms

-> Dental History

-> Family History

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