Welcome to the Koala Center for Sleep Disorders

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1 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 care you deserve, we may need to communicate with other healthcare professionals on your team. Please list all of the following professionals who you currently see. Thank you! Name DOB Primary Care Physician City, State Sleep Physician City, State Ears, Nose, Throat City, State Dentist City, State Chiropractor City, State Eye Doctor City, State Other City, State

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5 KOALA CENTER FOR SLEEP DISORDERS Patient Registration Today s Date _ Last Name First Name Middle Initial Address Zip Code Sex: Male / Female Do you live at this address for 6+ months out of the year? Yes / No Address Please which number is the best for you: If no, please provide additional address: City, State _ Zip Code Marital Status: Home Phone ( ) ( ) Single ( ) Married ( ) Divorced Work Phone ( ) ( ) Legally Separated Cell Phone _ ( ) Date of Birth: Address: _ Patient s Employer: Occupation: Social Security #: _ Preferred Language Ethnicity: Race: ( ) American Indian or Alaska Native ( ) Hispanic or Latino ( ) Not Hispanic or Latino ( ) Native Hawaiian or Other Pacific Islander ( ) Unknown ( ) Decline to Answer ( ) Black or African American ( ) Asian ( ) White ( ) Other Race ( ) Decline Responsible Party (if other than patient): Last Name First Name Middle Initial Address Zip Code Sex: Male / Female Employer: Title: DOB: Medical Insurance Information (please bring cards so we can copy for your file) Primary Insurance Carrier: Subscriber Name: Group Name (Employer) Relationship of Subscriber to patient: Secondary Insurance Carrier: _ Subscriber Name: Group Name (Employer) Relationship of Subscriber to patient: Group #: Member ID: Ins Company Phone #: Subscriber Birthdate: Group #: Member ID: Ins Company Phone #: Subscriber Birthdate: Referral Information: (please be specific- name of person, physician or marketing source- list more than one if applicable) How did you hear about our office? Which medical doctor(s) would you like us to communicate your treatment with? Referred to us by this doctor? Y / N Primary Care Physician Name City, State ( ) Specialist Physician Name _ City, State ( )

6 EPWORTH SLEEPINESS SCALE PATIENT NAME AGE DOB TODAYS DATE ACTIVITY SITTING AND READING WATCHING TV SITTING, INACTIVE IN A PUBLIC PLACE (THEATER, MEETING, ETC) AS A PASSENGER IN A CAR FOR AN HOUR WITHOUT A BREAK LYING DOWN TO REST IN THE AFTERNOON WHEN CIRCUMSTANCES PERMIT SITTING AND TALKING TO SOMEONE SITTING QUIETLY AFTER LUNCH WITHOUT ALCOHOL IN A CAR, WHILE STOPPED FOR A FEW MINUTES IN TRAFFIC TOTAL TOTAL Please mark if you suffer from or have been told you have any of the following: Loud Snoring Frequent Nightime Urination Daytime Tiredness Diabetes Depression Acid Reflux CPAP Intolerance Lack of Energy Using the scale provided, please answer how likely you are to doze off or fall asleep in the following situations, if you allowed yourself to do so: 0 = Would never doze 1 = Slight Chance of Dozing 2 = Moderate Chance of Dozing 3 = High Chance of Dozing Told you stop breathing during sleep Obesity/ Weight Gain Inability to Lose Weight Wake up Gasping SCORE COPD Thyroid Dysfunction Never Feel Rested High Blood Pressure Morning Headaches Decreased Concentration For Women Only: Pregnant Postmenopausal Premenopausal Polycystic Ovary Syndrome Hysterectomy Check Below: HEADACHES JAW JOINT PAIN JAW JOINT NOISE OR CLICKING LIMITED MOUTH OPENING EAR CONGESTION DIZZINESS RINGING IN EARS DIFFICULTY SWALLOWING LOOSE TEETH CLENCHING OR GRINDING FACIAL PAIN SENSITIVE TEETH CHEWING DIFFICULTIES NECK PAIN POSTURAL PROBLEMS TINGLING IN FINGERTIPS HOT & COLD TEETH SENSITIVITY NERVOUSNESS OR INSOMNIA SIGNS & SYMPTOMS OF ORAL/FACIAL PAIN (Please circle all symptoms that apply)

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