Patient: Date: Please describe your tooth sensitivity pain to a 5 second ice water swish:
|
|
|
- Egbert Shepherd
- 5 years ago
- Views:
Transcription
1 DTR/FDH Scaling Form Patient: Date: A) Tooth Sensitivity Pain Scale Office Use: Rate your tooth sensitivity pain on a scale from 0 to 10: With EMG W/O EMG 0 no pain whatsoever preop postop 1 I almost never feel it Canine Rise # s 3 I m aware of it several times a week 5 pain that just barely needs store bought medication 7 I really should see my dentist 9 I must have stronger medication and need to see my dentist today! 10 THE worst possible pain! Please describe your tooth sensitivity pain to a 5 second ice water swish: No Pain B) Occlusion/Bite Related Questions Do you: PLEASE CIRCLE THE NUMBER IF YES : 1- drink cold drinks through a straw to prevent a painful response in your teeth? 2- experience that tooth sensitivity pain dissipates rapidly? 3- have trouble eating crunchy or chewy foods? 4- have trouble drinking a cold drink or eating ice cream? 5- experience pain in your teeth when breathing in cold air that dissipates when you close your mouth and breathe through your nose? 6- experience a transient sensitivity pain in several of your teeth or a general area? 7- feel that your jaw and cheek muscles are often tight? 8- notice that chewing gum or chewy foods makes your jaw tired? 9- clench or grind your teeth? 10- notice that you consciously keep your lower teeth from touching your upper teeth because your teeth hurt slightly if not? 11- find yourself sticking your tongue between your front teeth sometimes? C) Less Related to Occlusion Questions Do you: PLEASE CIRCLE THE NUMBER IF YES: Very Painful 12- feel that your tooth sensitivity pain lingers long after the hot or cold stimulus is gone? 13- experience lingering pain after separating your teeth between crunchy foods? 14- feel that cold makes the pain in your tooth or teeth feel better? 15- experience pain in your tooth or teeth that wakes you up at night? 16- notice that you consciously keep your lower teeth from touching your upper teeth because your teeth hurt unbearably if not? 17- find that you must put something between your front teeth or the pain is unbearable? 18- think that you know exactly the one tooth that s causing your pain? 19- feel that you cannot open your jaw as far as you used to? 20- feel that hot drinks are intolerable and lead to a very painful response? CONTINUED ON BACK
2 D) Headache/Tension Related Questions (answer if you experience headaches): Do you: PLEASE CIRCLE THE NUMBER IF YES: 21- have debilitating headaches that require a trip to your physician? 22- have mild headaches that only require over the counter medication? 23- feel that the headaches are new to you? 24- get LIGHT SENSITIVE when you have headaches? 25- get NAUSEOUS when the headaches happen? 26- find that the headaches are IMPACTING your work, school, or recreational activities? 27- find that the headaches are intense and throbbing? 28- get upper neck tension or pain with your headaches? 29- get shoulder tension or with your headaches? 30- feel that you have been >50% disabled from your headaches for more than 11 of the last 90 days? E) Past Providers/Therapies Have you seen a dentist before for these symptoms? Have you seen a Primary Care Doctor before for these symptoms? Have you seen an ENT Specialist before for these symptoms? Have you seen a Neurologist before for these symptoms? Have you seen a Chiropractor before for these symptoms? Have you tried, Acupuncture Massage Therapist, or Physical Therapist?
3 F) Please take a photo of your teeth with back teeth together, and lips retracted. This is a very important step for patients traveling from long distances
4 Doyousuferfrom anyofthefolowing? Circleanysymptomsyousuferfrom PatientName: Date: EarProblems Hissing,BuzzingorRinging DecreasedHearing EarPain,EarAche,No Infection Clogged, Itchy ears Vertigo,Dizziness Jaw Problems Clicking,PoppingJaw Joints GratingSounds PaininCheekMuscles UncontrolableJaw and/or TongueMovements NeckProblems LackofMobility,Stifness NeckPain Tired,SoreMuscles ShoulderAchesandBack Aches Arm andfingernumbness and/orpain and/orpain HeadPain,Headache Forehead Temples Migraine Type SinusType ShootingPainUpBackof Head Hairand/orScalpPainful Hairand/orScalpPainful totouch BrainFog Eyes PainBehindEyes BloodshotEyes MayBulgeOut SensitivetoSunlight WeepingEyes DoubleVision ProblemsTrackingWhilereading ProblemsTrackingWhilereading EyeMuscleTwitching Mouth Discomfort LimitedOpeningofMouth InabilitytoOpenSmoothly Jaw DeviatestoOneSide WhenOpening LocksShutorOpen Can tfindbite Can tfindbite Throat SwalowingDificulties Laryngitis SoreThroatWithNoInfection VoiceIregularitiesorChanges FrequentCoughingorConstantClearingofThroat FeelingofForeignObjectinthroatConstantly Feelingof"handrestingonthroat" Feelingof"handrestingonthroat" Teeth Clenching,GrindingatNight LoosenessandSorenessofBackTeeth ToothSensitivitytoColdorIce Dr.BenA.Suter,DMD,FAGD,FICCMO,LVIF
5 EPWORTH SLEEPINESS SCALE Use the following scale to choose the most appropriate number for each situation: 0 = would never doze or sleep. 1 = slight chance of dozing or sleeping. 2 = moderate chance of dozing or sleeping. 3 = high chance of dozing or sleeping. Fill in your answers and see where you stand. Situation Chance of Dozing or Sleeping Sitting and reading Watching TV Sitting inactive in a public place Being a passenger in a motor vehicle For an hour or more Lying down in the afternoon Sitting and talking to someone Sitting quietly after lunch (no alcohol) Stopped for a few minutes in traffic While driving Total score (add the scores up) (This is your Epworth Score) Do you snore? Yes No Does your spouse snore? Yes No
Facial Problem(s) Questionnaire
Facial Problem(s) Questionnaire Full Legal Name: _ Birth Date: Referred by: Referring Dr s Phone#: Referring Dr s Email address: _ Christopher M. Anderson, DMD 1225 Johnson Ferry Road Suite 660 Marietta,
Welcome to the Koala Center for Sleep Disorders
Welcome to the Koala Center for Sleep Disorders Your health is very important. We are honored to have the opportunity to join you on your wellness journey. In order to provide you with the comprehensive
Patient Adult Information History
Patient Adult Information History Patient name: Age: Date: What is the main reason for today s evaluation? Infant History Birth delivery: Normal C-section Delayed Epidural Premature: No Yes If yes, how
Facial Problem Questionnaire
Facial Problem Questionnaire Name Age Date Referred by _ Referring Dr. s Phone # and Email: 1. Which of the following do you have (circle all that apply) Headaches Neck Pain Jaw pain Ear Pain Facial Pain
The following questions are about your sleep. Please consider both what others have told you about your sleep and what you know yourself.
Sleep History Form FORM CODE: SLE VERSION A 1/29/2009 PARTICIPANT ID NUMBER: CONTACT YEAR: 0 9 LAST NAME: INITIALS: INSTRUCTIONS: This form should be completed during the participant's clinic visit. ID
Sleep Disorders Diagnostic Center 9733 Healthway Drive, Berlin, MD , ext. 5118
Sleep Questionnaire *Please complete the following as accurate as possible. Please bring your completed questionnaire, insurance card, photo ID, Pre-Authorization and/or Insurance referral form, and all
PEDIATRIC SLEEP EVALUATION
PEDIATRIC SLEEP EVALUATION Directions: Please answer each of the following questions by writing in or choosing the best answer. This will help us know more about your family and your child. CHILD S INFORMATION
*521634* Sleep History Questionnaire. Name of primary care doctor:
*521634* Today s Date: Sleep History Questionnaire Appointment Date: Please answer the following questions before coming to your appointment. Please arrive 15 minutes early with this packet filled out.
THE PERMANENTE MEDICAL GROUP
Patient label here THE PERMANENTE MEDICAL GROUP Division of Sleep Medicine COMPLETED BY: PARENT/GUARDIAN CHILD/ADOLESCENT Age: Height: Weight: PEDIATRIC SLEEP QUESTIONNAIRE Thank you completing this questionnaire.
Sleep History Questionnaire B/P / Pulse: Neck Circum Wgt: Pulse Ox
2700 Campus Drive, Ste 100 2412 E 117 th Street Plymouth, MN 55441 Burnsville, MN 55337 P 763.519.0634 F 763.519.0636 P 952.431.5011 F 952.431.5013 www.whitneysleepcenter.com Sleep History Questionnaire
Denver, CO Welcome Packet
Fax: (303) 957-5414 or 720-542-8699 For any after-hours questions, please call (303) 956-5145 Dear Mountain Sleep Patient, You have been scheduled for a sleep study at 1210 S Parker Road, Suite 101, Denver,
Littleton, CO Welcome Packet 8151 Southpark Lane, Suite 200 Littleton, CO 80120
Littleton, CO Welcome Packet For any after-hours questions, please call (303) 956-5145 Dear Mountain Sleep Patient, You have been scheduled for a sleep study at 8151 Southpark Lane, Suite 200, Littleton,
604 NORTH ACADIA ROAD, Suite 210 THIBODAUX, LA SLEEP HISTORY QUESTIONNAIRE
604 NORTH ACADIA ROAD, Suite 210 THIBODAUX, LA 70301 985-493-4759 SLEEP HISTORY QUESTIONNAIRE DATE: / / NAME: AGE (First) (Middle) (Last) ADDRESS: (Street) (City) (State) (Zip) PHONE: Home( ) Work:( )
130 Preston Executive Drive Cary, NC Ph(919) Fax(919) Page 1 of 6. Patient History
130 Preston Executive Drive Cary, NC 27513 Ph(919)462-8081 Fax(919)462-8082 www.parkwaysleep.com Page 1 of 6 Patient History *Please fill out in dark BLACK INK only. General Information Name Sex: Male
Sleep Symptoms & History
Sleep Symptoms & History In your own words, please tell us what brings you to the sleep clinic today? How long have you been experiencing your sleep problems? yrs. mos. To give us a precise understanding
Patient Information. Name: Date of Birth: Address: Number & Street City State Zip Code. Home Number: ( ) Cell Number: ( )
Patient Information Name: Date of Birth: Age: Address: Number & Street City State Zip Code Home Number: ( ) Cell Number: ( ) Social Security Number: Marital Status: Religion: Race: Height: Weight: Sex:
SNORING AND OBSTRUCTIVE SLEEP APNOEA WAYS TO DEAL WITH THESE PROBLEMS
SNORING AND OBSTRUCTIVE SLEEP APNOEA WAYS TO DEAL WITH THESE PROBLEMS Laugh and the world laughs with you; snore and you sleep alone. These words by novelist Anthony Vergess ring true with all too many
Sleep History Questionnaire
Sleep History Questionnaire Name: DOB: Phone: Date of Consultation: Consultation is requested by: Primary care provider: _ Preferred pharmacy: Chief complaint: Please tell us why you are here: How long
PLEASE INDICATE ANY OF THE FOLLOWING YOU ARE NOW EXPERIENCING:
DATE OF HEALTH HISTORY UPDATE: THIS IS A HEALTH HISTORY UPDATE. PLEASE INDICATE ANYTHING REGARDING YOUR HEALTH (MEDICAL AND DENTAL) THAT HAS CHANGED SINCE YOUR LAST VISIT TO OUR OFFICE. THANK YOU. WHAT
SLEEP SCREENING QUESTIONNAIRE
Patient Information 433 W. University Dr. Rochester, MI 48307 www.rochesteradvanceddentistry.com +1 248 656-2020 SLEEP SCREENING QUESTIONNAIRE Name: DOB: Age: Address: Employer: SS# Home Phone: Work Phone:
Balboa Island Dentistry (949)
Do You Snore? Are you always tired? Snoring is no laughing matter! It may be more than an annoying habit. It may be a sign of. How well do you sleep? Just about everyone snores occasionally. Even a baby
Baptist Health Floyd 1850 State Street New Albany, IN Sleep Disorders Center Lung & Sleep Specialists. Date of Birth: Age:
Page 1 of 7 GENERAL INFORMATION Name: Date of Birth: Age: Social Security #: Sex: Height: Weight: Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Employer s Name: Marital Status: Married
Huron Medical Sleep Center Saad S. Ahmad, MD
Authorization and Consent for Sleep Testing I authorize the release of any medical information necessary to the durable medical equipment company for therapy, if applicable. I authorize the use of audio
Sleep History Questionnaire
Location South Loop Katy Steeplechase Fort Bend NAME ADDRESS PHONE SEX DOB AGE HEIGHT WEIGHT NECK COLLAR SIZE (inches) Do you have difficulty falling asleep? Is your sleep restless or disturbed? Do you
493 Blackwell Road, Suite 317-A, Warrenton, VA
493 Blackwell Road, Suite 317-A, Warrenton, VA. 20186 Dear Sleep Study Patient, Attached is the patient questionnaire for your sleep study. Please complete and mail or fax the enclosed forms as soon as
SLEEP HISTORY QUESTIONNAIRE
Date of birth: Today s date: Dear Patient: SLEEP HISTORY QUESTIONNAIRE Thank you for taking the time to fill out a sleep history questionnaire. This will help our healthcare team to provide the best possible
TMD: CONSERVATIVE TREATMENT AND PHYSICAL THERAPY OPTIONS
TMD: CONSERVATIVE TREATMENT AND PHYSICAL THERAPY OPTIONS Massage: The temporalis on the side of the head is easy to locate. Press on it looking for painful nodules, massaging gently. Opening and closing
EPWORTH SLEEPINESS SCALE
EPWORTH SLEEPINESS SCALE Name: Sponsors last 4 of SSN#: DOB: Today s Date: Age (years): Gender (circle): MALE FEMALE How likely are you to doze off or fall asleep in the following situation, in contrast
General Information. Name Age Date of Birth. Address Apt. # City State Zip. Home Phone Work Phone. Social Security Number Marital Status
Accredited Member Center of The American Academy of Sleep Medicine 400 Riverside Drive, Suite 1500, Bourbonnais, IL 60914 Phone (815) 933-2874 Fax (815) 939-9413 www.riversidemc.net/sleep General Information
Orofacial Pain Examination Form
ADVANCED ORAL AND FACIAL SURGERY OF THE MAIN LINE, PC G. JOEL FUNARI, M.S., D.M.D. Orofacial Pain Examination Form Please complete pages 1 through 4. Circle choices whenever available. Name Date SSN DOB
PATIENT NAME: M.R. #: ACCT #: HOME TEL: WORK TEL: AGE: D.O.B.: OCCUPATION: HEIGHT: WEIGHT: NECK SIZE: GENDER EMERGENCY CONTACT: RELATIONSHIP: TEL:
SLEEP DISORDERS INSTITUTE HOSPITAL: DePaul Building Street Address City, State Zip Tel: (202) 555-1212 Fax: (202) 555-1212 SLEEP QUESTIONNAIRE PATIENT NAME: M.R. #: ACCT #: STREET ADDRESS: CITY: STATE:
WELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS
WELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS Prior to your office visit, we request that you complete this questionnaire. It asks questions not only about your sleeping habits and behavior
PATIENT DEMOGRAPHICS
PATIENT DEMOGRAPHICS NPSG CPAP CPAP Retitration Split Night PATIENT INFORMATION: Name: Last First Middle Initial Address: City: State: Zip: Social Security #: DOB: Gender: Age: Phone Number: Cell: Work:
ANNUAL FOLLOW-UP QUESTIONNAIRE
SLEEP HEART HEALTH STUDY - TUCSON ANNUAL FOLLOW-UP QUESTIONNAIRE - 2004 Dear Sleep Heart Health Study participant: Today s Date: / / Month Day Year Please take the time to complete and return this short
Huron Medical Sleep Center Saad S. Ahmad, MD
Authorization and Consent for Sleep Testing I authorize the release of any medical information necessary to the durable medical equipment company for therapy, if applicable. I authorize the use of audio
DESERT CENTER FOR ALLERGY AND CHEST DISEASES HEALTH QUESTIONAIRE NAME. PAST MEDICAL PROBLEMS- Check mark if you have any of the following
DESERT CENTER FOR ALLERGY AND CHEST DISEASES Pulmonary Medicine, Allergy/Immunology, Sleep Disorders Pulmonary Rehabilitation, Pulmonary Function Laboratory HEALTH QUESTIONAIRE NAME What is your presenting
PULMONARY & CRITICAL CARE CONSULTANTS OF AUSTIN 1305 West 34 th Street, Suite 400, Austin, TX Phone: Fax:
Name: Sex: Age: Date: Date of Birth Height Weight Neck size Referring Physician: Primary Care MD: Main Sleep Complaint(s) trouble falling asleep trouble remaining asleep excessive sleepiness during the
Patient Scheduled Letter Thunderbird Internal Medicine Sleep Center 5620 W. Thunderbird Rd., Suite C-1 Glendale, AZ (602)
Patient Scheduled Letter Thunderbird Internal Medicine Sleep Center 5620 W. Thunderbird Rd., Suite C-1 Glendale, AZ 85306 (602) 938 6960 Dear Patient, Your Doctor has requested you be scheduled for a sleep
PATIENTS DEMOGRAPHICS
PATIENTS DEMOGRAPHICS Date: First Name MI Last Name Sex: M or F (Circle one) Age: Address: City: State: Zip Code: Home Telephone: Work Telephone: Cell/Pager No: Date of Birth: Single: Married: Social Security
Huron Medical Sleep Center Saad S. Ahmad, MD
Authorization and Consent for Sleep Testing I authorize the release of any medical information necessary to the durable medical equipment company for therapy, if applicable. I authorize the use of audio
What s the name of your position?
What s the name of your position? What are some basic work responsibilities (e.g primarily front desk/administration, light lifting or heavy liftingplease indicate pounds)? CONSENT FORM FOR USE AND DISCLOSURE
ANNUAL FOLLOW-UP QUESTIONNAIRE
SLEEP HEART HEALTH STUDY - TUCSON ANNUAL FOLLOW-UP QUESTIONNAIRE - 2003 Dear Sleep Heart Health Study participant: Today s Date: / / Month Day Year Please take the time to complete and return this short
New Patient Evaluation Form
New Patient Evaluation Form Alfred Tennant, DDS TMJ, Facial Pain, Dental Sleep Medicine 33 Davis Blvd Tampa, FL 33606 Fax (813)658-6254 Phone (813)743-2352 Please complete pages 1-8 and circle choices
PATIENT SLEEP QUESTIONNAIRE
PATIENT SLEEP QUESTIONNAIRE Name: Date of Birth: Today s Date Primary Care Physician Telephone # Physician ordering test (Other than PCP): Physician s Tel. #: _ Age: Years Height: Feet Inches Weight: Lb
THE SLEEP DISORDERS CLINIC Medical Director: Dr Raymond Gottschalk PATIENT QUESTIONNAIRE
THE SLEEP DISORDERS CLINIC Medical Director: Dr Raymond Gottschalk 55 Frid Street, Unit 7, Hamilton, Ontario L8P 4M3 Phone:905-529-2259 Fax: 905-529-2262 282 Linwell Road, Suite 118, St. Catharines, Ontario
Humble Dreams Sleep Center. Humble, TX 77339
Humble Dreams Sleep Center 8901 FM 1960 Bypass West, Ste. 306 Humble, TX 77339 Dear Humble Dreams Sleep Study Patient, Thank you for allowing Humble Dreams Sleep Center to provide your sleep study as requested
Riley Sleep Evaluation Questionnaire
Directions Please answer each of the following questions by writing in or choosing the best answer. This will help us better understand your child and his or her sleep problems. Shade circles like t like
PATIENT QUESTIONNAIRE Boise Location 7272 W. Potomac Drive Boise, ID (208)
PATIENT QUESTIONNAIRE Boise Location 7272 W. Potomac Drive Boise, ID 83704 (208)884-2922 ***Questionnaire MUST be completed PRIOR to arrival for appointment*** Today s Date / / / / Last First MI DOB Referring
Intake Questionnaire
Intake Questionnaire In order to make the best use of your appointment time, please complete this form prior to your initial appointment. What is your name? (Who filled in this form?) (Y= yes N=no DK=
MICHIGAN INSTITUTE FOR SLEEP MEDICINE NEW PATIENT SLEEP QUESTIONNAIRE. Name: Date of Birth: / / Age: Sex: Address: City: Zip:
MICHIGAN INSTITUTE FOR SLEEP MEDICINE NEW PATIENT SLEEP QUESTIONNAIRE *Please bring copies of any recent Blood Work and Physician Sleep Referral Order* Please answer every question to the best of your
BMI: Family physician : Neck circumference (cm) Hypertension + 4 cm Snoring + 3 cm Witnessed apnea + 3cm Total
Last and first names: F M Date: Date of birth: / / YYYY MM DD Weight: kg /lbs Profession/job: Height: _ cm /ft.in. BMI:_ Family physician : ANC (adjusted neck circumference) : Neck circumference (cm) Hypertension
Comprehensive History, Consult, and Evaluation Form
1 Comprehensive History, Consult, and Evaluation Form 1.Patient Information: Today s Date: Mr. Ms. Miss Mrs. Dr. Name Age: Date of Birth: Male Female Address: City/State/Zip: Home Phone: Work Phone: Cell
Help I Have Problems with My Sleep!
Help I Have Problems with My Sleep! Over An 85 Year Lifespan Sleep 31% Work 21% Exercise 1% Food and Drink 11% Sleep Is Important! You can survive without food for up to 2 months Without water 3-5 days
Sleep History Questionnaire. Sleep Disorders Center Duke University Medical Center. General Information. Age: Sex: F M (select one)
Sleep History Questionnaire Sleep Disorders Center Duke University Medical Center Part I: General Information Name: Address: Date: Phone: Age: Sex: F M (select one) Education (years of school): Occupation:
EMORY SLEEP CENTER Sleep and Health Questionnaire
EMORY SLEEP CENTER Sleep and Health Questionnaire Demographics Today s Date: / / Name: Date of Birth: / / Address: Sex: Male Female City/State/Zip: Preferred Contact Number: Work Home Cell Occupation:
Patient History & Sleep Questionnaire
Patient History & Sleep Questionnaire Patient Full Name: Nick Name: Birth date: Age: Sex: Height: Current Weight: Weight Five Years Ago: Peak Lifetime Weight: Marital Status: Single Married Divorced Widowed
Sleep Study Information
Sleep Study Information Metroplex Hospital Sleep Center 2111 S. Clear Creek Rd. Killeen, TX 76549 (254) 519-8452 Report to sleep lab at your scheduled appointment time, do not arrive before this time.
New Patient Sleep Intake
New Patient Sleep Intake Name: Date of Birth: Primary Care Physician: Date of Visit: Referring Physician and/or Other Physicians: Retail Pharmacy: Mail Order Pharmacy: Address: Mail Order Phone #: Phone
SLEEP DISORDERS CENTER QUESTIONNAIRE
Carteret Health Care Patient's name DOB Gender: M F Date of Visit _ Referring physicians: Primary care providers: Please complete the following questionnaire by filling in the blanks and placing a check
LIPS TOGETHER AND TEETH APART
John T. Mahoney, D.D.S. Family Dentistry 2117 Old Jeanerette Road New Iberia, LA 70563 Telephone 337-365-5865 Fax 337-365-6137 LIPS TOGETHER AND TEETH APART One of the most important steps in breaking
RESEARCH DIAGNOSTIC CRITERIA FOR TEMPOROMANDIBULAR DISORDERS: REVIEW, CRITERIA, EXAMINATIONS AND SPECIFICATIONS, CRITIQUE
RESEARCH DIAGNOSTIC CRITERIA FOR TEMPOROMANDIBULAR DISORDERS: REVIEW, CRITERIA, EXAMINATIONS AND SPECIFICATIONS, CRITIQUE Edited by: Samuel F. Dworkin, DDS, PhD and Linda LeResche, ScD A. HISTORY QUESTIONNAIRE
Occupation: Usual Work Hours/Days: Referring Physician: Family Physician (PCP): Marital status: Single Married Divorced Widowed
Name Social Security No. Last First MI Address Phone No. ( ) City State Zip Secondary No. ( ) Date of Birth Sex (M/F) Race Email County Primary Care Marital Status Single Divorced Married Widowed Employer
Welcome to the office of
Welcome to the office of Date: 8340 Cleveland Avenue N. Canton, Ohio 44720 330.494.6305 PERSONAL INFORMATION (Please Print Legibly) Last Name: First Name: _ Middle Initial: _ SS #: _ I would prefer to
VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE
VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE Name:_ DOB: MR#: Date: Sex: Age: Height: Referring physician: Primary care physician: What is your primary sleep problem? Please explain any strange
Emergency Contact Information Name: Phone: Address: Employer Information Employer Name: Address/Street: City: Zip: Phone: Fax:
SUNSET SLEEP LABS PATIENT INFORMATION FORM Patient Information Name: Sex: M F Date of Birth: Address/Street: City: Zip: Phone: Alt Phone: Parent/Guardian: Phone: Social Security Number: Drivers License:
Associated Neurological Specialties and Sleep Disorder Center
Sleep Center Questionnaire Name: Sex: Age: Date: Date of Birth: Height: Weight: Neck Size: Primary Care Physician: Referring Physician: Main Sleep Issues/Complaints Trouble falling asleep Trouble staying
Sleep Center. Have you had a previous sleep study? Yes No If so, when and where? Name of facility Address
Patient Label For office use only Appt date: Clinician: Sleep Center Main Campus Highlands Ranch Location 1400 Jackson Street 8671 S. Quebec St., Ste 120 Denver, CO 80206 Highlands Ranch, CO 80130 Leading
2550 UNIVERSITY AVE WEST SUITE 143N ST. PAUL, MN (651) FAX (651)
2550 UNIVERSITY AVE WEST SUITE 143N ST. PAUL, MN 55114 (651) 642-1013 FAX (651) 642-0947 www.mncranio.com Welcome to the Minnesota Craniofacial Center for TMJ & Sleep Treatment, one of the few clinics
Tallahassee Memorial Sleep Center Patient Questionnaire
Tallahassee Memorial Sleep Center Patient Questionnaire Name _ Age Date Date of Birth Sex Height ft in Weight lbs Neck size inches (If known) Body Mass Index (BMI) (If known) Phone(s) (home) (work) (cell)
Instructions. If you make a mistake, put an "X" over the checkmark. Then put a checkmark in the correct box and draw a circle around that box.
SLEEP HEART HEALTH STUDY SLEEP HABITS AND LIFESTYLE QUESTIONNAIRE Instructions Thank you for taking time to fill out the enclosed Sleep Habits Questionnaire. Please fill out the form completely. You may
MEDICAL HISTORY QUESTIONNAIRE
MEDICAL HISTORY QUESTIONNAIRE NAME: SEX: DATE: DOB: AGE: Primary Doctor / Care Manager: Additional doctors to receive sleep study results: Chief sleep related complaint: What made you decide to have this
Welcome to the Minnesota Craniofacial Center for TMJ & Sleep Treatment!
2550 UNIVERSITY AVE WEST SUITE 143N ST. PAUL, MN 55114 (651) 642-1013 FAX (651) 642-0947 www.mncranio.com Welcome to the Minnesota Craniofacial Center for TMJ & Sleep Treatment! Snoring used to be considered
Medical History Questionnaire
Medical History Questionnaire OFFICE USE Patient ID: FORM DATE: / / NAME: DATE OF BIRTH: / / Allergens No known allergens Iodine Plastic Antibiotics Latex Sedatives Aspirin Local anesthetics Sleeping pills
Last Name: First Name: Address: City: State: Zip: Home #: Work #: Mobile #: Gender: SS#: DOB: Marital Status: Employer:
Thank you for the opportunity to evaluate your dental condition. In order to provide the best service for you, please complete the following information. About You Last Name: First Name: Address: City:
Sleep Medicine Associates
Date: Patient Name: DOB: Patient Height: _ Weight: _ lbs Referring Physician: Neck Size: Main Sleep Problems: 1. My main sleep complaint is: Trouble Sleeping at night Sleepy during the day Unusual behavior
Not Sleepy HO Q1 D2 Q3 Q4 ]5 D6 j7 Q8 Q9 Q10 Extremely Sleepy
![Not Sleepy HO Q1 D2 Q3 Q4 ]5 D6 j7 Q8 Q9 Q10 Extremely Sleepy](/thumbs/96/127246551.jpg "Not Sleepy HO Q1 D2 Q3 Q4 ]5 D6 j7 Q8 Q9 Q10 Extremely Sleepy")
Health Benefits Employee Services HBE Preventive Health - Sleep Assessment Form Please bring your completed assessment form to your appointment. To schedule an appointment please call 505 844-HBES (4237).
Narendra Kumar, M.D. PC Board Certified ENT Board Certified Sleep Medicine
Narendra Kumar, M.D. PC Board Certified ENT Board Certified Sleep Medicine PATIENT DEMOGRAPHICS Who is the Physician that referred you to us? Who is the primary care Physician? Date: Do you want this report
SLEEP SCREENING QUESTIONNAIRE
SLEEP SCREENING QUESTIONNAIRE Please answer each question accurately and to the best of your knowledge, to help us obtain an accurate picture of your health and sleep issues, only this way will we be able
Robert E. McMichael, M.D. Medical Director Patient Instructions for a Diagnostic Sleep Study
NORTH TEXAS SLEEP DISORDERS CENTER Neurology Associates of Arlington, P.A 811 West Interstate 20, Suite G12 Arlington, Texas 76017 (817) 419-6375 Fax (817) 419-6371 Robert E. McMichael, M.D. Medical Director
SLEEP STUDY - PATIENT QUESTIONNAIRE
NOTE: You cannot fill out this form on Mozilla Firefox, please try another browser. You have two options for completing a questionnaire: - Enter the information on the fillable PDF and click Print at the
Kelowna Sleep Clinic Dr. Ronald Cridland Inc Sleep Questionnaire
Dr. Ronald Cridland Inc Sleep Questionnaire Name: Date: d/m/yr Date of Birth: d/m/yr Age: Marital Status: Sex: M F Address: City: Province: Postal Code: Health Care #: Home Phone #: Work Phone #: _ Cell
Brunswick Pulmonary and Sleep Medicine Lawrence Davanzo, DO, FCCP 49 Veronica Ave, Somerset, NJ Phone# Fax#
REGISTRATION FORM (Please Print) Today s date: PCP: PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid If not, what is
Insurance information
Pediatric Sleep Intake Paperwork Today s date: Completed intake paperwork helps our providers get to know patients and their medical history. We rely on its accuracy and completeness to provide the best
PATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:
PATIENT REGISTRATION Patient's Name (Last, First, MI): Date of Birth: Age: Sex: M / F Social Security Number: Address: Apt. # City: State: Zip: Home Number: Mobile Number: Work Number: Employment Status:
CENTRAL FLORIDA ORAL & MAXILLOFACIAL SURGERY, PA PATIENT REGISTRATION Date: PATIENT INFORMATION
CENTRAL FLORIDA ORAL & MAXILLOFACIAL SURGERY, PA PATIENT REGISTRATION Date: Pre-fix: Patient s Legal First Name: PATIENT INFORMATION Legal Last Name: Nickname: Mr Mrs Ms Dr Street Address: Home Phone #:
Height: Weight: Neck Size: Does your work involve shift work? Yes No. Where did you hear about us: Physician Media Friend Other
Personal Information Name: Date of birth: Sex: Male Female Marital Status: Nationality: MRN(for KAUH Patients): Height: Weight: Neck Size: Address: Occupation: Length of work day: Does your work involve
What is the chief complaint for which you are seeking treatment in our practice?
Call 1300 7SNORE www.puresleepservices.com.au New Patient Form Please take your time to answer these questions as completely as possible. It will assist us greatly in our effort to provide the best treatment
SLEEP SCREENING QUESTIONNAIRE
SLEEP SCREENING QUESTIONNAIRE This questionnaire was designed to provide important facts regarding the history of your sleep condition. To assist in determining the source of any problem, please take your
Nash Sleep Disorders Center 250 Medical Arts Mall Suite C Rocky Mount NC Phone: Fax:
Appointment Date: Arrival Time: *Please give at least 24 hour notice if you are unable to keep your appointment or need to reschedule. 1. Patients will need to bring pictured identification, insurance
Emad F. Abdallah, DMD, MS Member, American Association of Orthodontists Diplomate, American Board of Orofacial Pain
Patient s Date: Age: Sex: Date of Birth: Home Occupation: Chief Complaint: Duration of the problem: Problem most severe: Morning Afternoon Evening Sleeping Eating No pattern SYMPTOMS Left Right Face Pain
Please do not write in this space.
Facial Problem Questionnaire I. Name Age Date Referred by II. Which of the following do you have (circle all that apply) Headaches Neck Pain Jaw pain Ear Pain Facial Pain Bite Problems Damaged teeth Other
1960 FP CENTER FOR SLEEP DISORDERS
1960 FP CENTER FOR SLEEP DISORDERS Sleep Questionnaire Name: Date: Date of Birth: / / Age: Gender: Height: Weight: lbs. Referring Physician: Occupation: Please give a brief description of your sleep problem
PATIENT NAME: DATE: Phone#: On the diagram below, please shade the areas of pain:
PATIENT INTAKE: TMJ HISTORY PATIENT NAME: DATE: EMAIL: Phone#: On the diagram below, please shade the areas of pain: Date your symptoms began: What symptoms are you experiencing in your jaw? Right or Left:
Please answer as many ques ons as you can before your ini al visit to EvergreenHealth Sleep Services.
Please answer as many ques ons as you can before your ini al visit to EvergreenHealth Sleep Services. Pa ent Iden fica on: Pa ent name: Date: Age: Date of birth: Who is filling out this ques onnaire? Please
Sleep Questionnaire Name: Sex: Age: Da te: Da te of birth: Height: Weight: Neck siz e: Ref erring Physician: Primary Car e MD:
www.myvcmf.com 1133 E. Stanley Blvd., Suite 101 Livermore, CA 94550 925 454-4280 5725 W. Las Positas Blvd., Suite 110 Pleasanton, CA 94588 925-416-6767 Sleep Questionnaire Name: Sex: Age: Da te: Da te
Sleep Screening Questionnaire
Version: SLPQV1 Sleep Screening Questionnaire OFFICE USE Patient ID: NAME: CURRENT DATE: / / DATE OF BIRTH: / / MALE FEMALE Referring Physician: Contact ID: Number Number #1 = the most severe symptom #1
Your physician has ordered a sleep study for you on. Your arrival time is scheduled for.
Dear Patient: Your physician has ordered a sleep study for you on. Your arrival time is scheduled for. The Texas State Sleep Lab is located in the Health Professions Building on the Texas State University
Your appointment is scheduled for at with Dr. Dimitri Markov.
Jefferson Sleep Disorders Center Dear prospective patient: We thank you for choosing the Jefferson Sleep Disorders Center, At the Navy Yard. 3 Crescent Drive, in Suite 100 (on site parking) 215-503-3300
Sleep Disorders Questionnaire
Sleep Disorders Questionnaire NAME: DATE: ADDRESS: DATE OF BIRTH: AGE: SEX: HOME PHONE: WORK PHONE: CELL PHONE: MARITAL STATUS: SINGLE: MARRIED: WIDOW(ER): DIVORCED: SEPARATED: REFERRING PHYSICIAN: ADDRESS: