What is the chief complaint for which you are seeking treatment in our practice?
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- Anabel Lang
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1 Call SNORE 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 for you. Name Date... DOB... Preferred Name Home Phone... Work... Mobile... Address Occupation... Preferred method contact? Phone SMS How did you hear about our practice?... Are you in a health fund? If yes, which one?... Person responsible for paying the fees... GP Name... GP Phone... GP Address... Are you currently under medical care?... For what reason?... Medicare.... Reference Number... Expiry Date... What is the chief complaint for which you are seeking treatment in our practice? 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 for you. Recent Chronic (6 Mths+) Recent Kicking or Jerking legs Significant daytime drowsiness Swelling in ankles or feet Frequent heavy snoring Morning Hoarseness Affects sleep of others Dry mouth upon waking Gasping when waking Fatigue Told that I stop breathing during sleep Difficulty falling asleep Night time choking spells Tossing and turning frequently Unable to tolerate C-PAP Repeated awakening Tooth grinding Feeling unrefreshed in the morning Teeth crowding Chronic (6 Mths+) Any other issues you would like to discuss?...
2 CARDIOVASCULAR HAEMATOLOGIC NEUROLOGIC Heart attack Blood transfusion Vision problems High blood pressure Anemia Glaucoma Heart murmur Hemophilia Migraines Heart palpitations Leukemia Fainting or dizzy spells Heart valve disease Tendency to bleed longer Stroke Heart surgery than normal Epilepsy or seizures Heart pacemaker HIV Panic attack Rheumatic fever Bruising Easily Phobias Congenital heart defect Tumor or Cancer Huntington s Disease Arrhythmias Radiation therapy Enlarge lymph nodes or gland Aneurysm Chemotherapy Multiple Sclerosis Other heart problems Neuralgia Irregular heart beat PULMONARY Parkinson s Disease Shortness of breath Allergies or hives Nervous System Disorder Fluid Retention Asthma Anxiety Disorder Emphysema Depression Chronic bronchitis Difficulty concentrating GASTROINTESTINAL Tuberculosis (TB) Memory loss Stomach/Intestinal ulcer Breathing difficulties Excessive thirst Colitis Sarcoidosis Psychiatric Care Irritable bowel syndrome Difficulty breathing at night Slow healing sores Persistent diarrhea Speech difficulties Hepatitis or liver disease Nausea/Vomiting SLEEP DERMAL/MUSCULOSKETAL Reflux disease Frequent awakening at night Cold Sores/Herpes Intestinal Disorder Snoring Allergy to latex (Rubber) Constipation Sleep Apnea Skin rash/other skin disorders Gall Bladder problem/stones Insomnia Osteoarthritis Restless legs Osteoporosis Restless sleep Rheumatoid arthritis ENDOCRINE Tiredness in the morning Systemic Lupus Diabetes Feeling sleepy during the Artificial (Prosthetic) joint Insulin Resistance Fibromyalgia Hypoglycemia Chronic Fatigue Syndrome Recent Weight Gain Muscle weakness/cramps Recent Weight Loss GENITOURINARY Cold hands and feet Thyroid disease Kidney, Bladder problem Muscle aches Hormone replacement therapy Reproductive system problem Muscle fatigue Change of libido Ovarian Cyst Muscle spasm Urinary tract Infection Muscle tremors Menstrual Problems Poor circulation Kidney stones Swollen, stiff or painful joints Renal/Kidney failure Tired muscles
3 Current Medications Please list all medications you are taking and the reason you take them. Include all over the counter medications, vitamins, herbs etc MEDICATION DOSAGE REASON FOR TAKING TIME OF DAY Personal Information Do you drink 4 or more cups of coffee per day? Do you smoke tobacco? Do you consume alcohol or take sedatives? Do you take recreational drugs? Do you have allergies or intolerance to any medications, foods or Environmental factors? If so, please list... In the last year, have you drunk alcohol or used drugs more than you meant to? Have you felt you need to cut down on your drinking or drug use in the last year Have any family members had heart disease/high blood pressure/diabetes? Do any family members snore, or have OSA or a sleep disorder? Family History If yes, who?...
4 Current Medications Please select or answers based on your average sleep experience and/or what a sleep partner has told you Sleep Positions: Side Back/Stomach/Varies Is it easy to fall asleep? How long does it take you to fall asleep in bed?... How many hours sleep do you obtain each night?... Do you feel rested upon AM waking? Have you been told you stopped breathing and gasp during sleep? Do you wake often during the night? Do you have difficulty falling asleep again overnight after awakening? Do you wake up refreshed the next day? Do you often wake feeling tired? Do you grind or clench your teeth in your sleep? Do you often wake in the morning with a headache? Do you feel pain in your jaw joints (in front of the ear)? Do you have problems concentrating for long periods of time? Have you ever had a Sleep Study (PSG)? If so, what was the result?... Additional Sleep Apnea Symptoms Sore, dry throat on waking Morning headache Nycturia (Having to get up to pass urine repeatedly Decreased sex drive or impotence Gastro-esophageal reflux Personality changes, which may include irritability Decreased job performance Choking or gasping during sleep Anxiety or depression Poor concentration/memory Have you got any of the following: High blood pressure Type 2 diabetes Atrial fibrillation Congestive heart failure
5 Berlin Questionnaire Category 1 1. Do you snore? Don t know 2. Your snoring is Slightly louder than breathing as loud as talking Louder than talking very loud can be heard in adjacent room 3. How often do you snore? Nearly every night 4. Has your snoring ever bothered other people? Don t know 5. Has anyone noticed that you stop breathing during your sleep? Nearly every night Category 2 6. How often do you feel tired or fatigued after your sleep? Nearly everyday 7. During your wake time, do you feel tired, fatigued or not up to par? Nearly everyday 8. Have you ever nodded off or fallen asleep while driving a vehicle? 9. If yes, how often has Nearly every night Category Do you have high blood pressure? Don t know
6 Epworth Sleepiness Scale (How likely are you to fall asleep in the following situations?) 0 = no chance of dozing 1 = slight chance of dozing 2 = moderate chance Situation 3 = high chance Chance of dozing (0-3) Sitting and Reading Sitting inactive in a public place (eg theatre/meeting) As a passenger in a car for an hour without a break Sitting quietly after lunch without alcohol Watching TV Lying down to rest in the afternoon (when circumstances permit) Sitting and talking to someone In a car, while stopped for a few minutes in traffic Total score Office Use Only History of missing teeth: Extractions: Premature birth: Hypermobility:
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