SLEEP SCREEIG QUESTIOAIRE 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 time and answer each question as completely and honestly as possible. Please sign each page. Patient Information TODAY'S DATE: q MR. q MS q MISS AME: q MRS. q DR. FIRST MIDDLE TIAL LAST AGE: BIRTH DATE CITY/STATE/ZIP. HOW LOG AT CURRET ADDRESS? PREVIOUS EMPLOD BY: q Male q Female (IF LESS THA THREE ARS, PLEASE GIVE PREVIOUS ADDRESS) SS#: HOME PHOE: WORK PHOE: CELL PHOE: EMAIL: RESPOSIBLE PARTY: FAMILY PHYSICIA: FAMILY DETIST: Please list other health care practitioners seen in the last 9 months: ISURACE MEMBER UMBER GROUP UMBER PLA UMBER AME OF PRIMARY CARE PHYSICIA HEIGHT: feet inches WEIGHT: pounds REFERRED BY: WHAT ARE THE CHIEF COMPLAITS FOR WHICH YOU ARE SEEKIG TREATMET? Please number the complaints with #1 being the most important. Other: Frequent heavy snoring which affects the sleep of others Significant daytime drowsiness I have been told that "I stop breathing" when sleeping. Difficulty falling asleep Gasping when waking up ighttime choking spells Feeling unrefreshed in the morning Morning hoarseness Morning headaches Swelling in ankles or feet octurnal teeth grinding Jaw pain Facial pain Jaw clicking 2006 TMJ PRACTICE MAAGEMET ASSOCIATES, IC. 1.800.879.6468. REPRIT RIGHTS OLY THROUGH LICESIG. Page 1
Sleep Center Evaluation Have you ever had an evaluation at a Sleep Center? 111 Yes 111 o If Yes: Sleep Center ame and Location Sleep Study FOR OFFICE USE OLY q mild The evalution confirmed a diagnosis of: 111 moderate obstructive sleep apnea q severe The evaluation showed an RDI of and an AHI of CPAP Intolerance (Continuous Positive Airway Pressure device) If you have attempted treatment with a CPAP device, but could not tolerate it please fill in this section: I could not tolerate the CPAP device due to: q mask leaks q I was unable to get the mask to fit properly q discomfort caused by the straps and headgear q disturbed or interrupted sleep caused by the presence of the device q noise from the device disturbing my sleep and/or bed partner's sleep 111 CPAP restricted movements during sleep q CPAP does not seem to be effective q pressure on the upper lip causing tooth related problems q a latex allergy q claustrophobic associations q an unconscious need to remove the CPAP apparatus at night Other: Other Therapy Attempts What other therapies have you had for breathing disorders? (weight-loss attempts, smoking cessation for at least one month, surgeries, etc.) 2006 TMJ PRACTICE MAAGEMET ASSOCIATES, IC. REPRIT RIGHTS OLY THROUGH LICESIG. Page 2
I List any medications which have caused an allergic reaction: E Antibiotics q Aspirin E Barbiturates E Codeine E Iodine E Latex D Local anesthetics D Metals D Penicillin E Plastic D Sedatives O Sleeping pills E Sulfa drugs Y q 1 n Heart pacemaker Heart valve replacement Heartburn or a sour taste in the mouth at night 7 Hepatitis 7 High blood pressure 7 Immune system disorder y q H Injury to Face eck Head q Mouth 7 Insomnia D D D Irregular heart beat Jaw joint surgery Low blood pressure Memory loss Migraines Morning dry mouth 7 Teeth D Muscle spasms or cramps eeding extra pillows to help breathing at night E ighttime sweating Other allergens: List any medications you are currently taking: O Antacids D Codeine yq il E Antibiotics y q IA Cortisone H D Anticoagulants D Diet pills D E Antidepressants y q E Heart medication yq q O Anti-inflammatory drugs (non-steroid) D Barbiturates E Blood thinners Medical History y o q Anemia D Arteriosclerosis E Asthma D Autoimmune disorders O Bleeding easily I 1 Chronic sinus problems D Chronic fatigue E Congestive heart failure 7 Current pregnancy D Diabetes D Difficulty concentrating D Dizziness O Emphysema D Epilepsy D Fibromyalgia E Frequent sore throats D Gastroesophageal Reflux Disease (GERD) D Hay fever 7 Heart disorder I I Heart murmur D Heart pounding or beating irregularly during the night y q O High blood pressure medication Insulin Muscle relaxants erve pills y q yq E y q Y E Osteoarthritis I I Osteoporosis D Poor circulation I Prior orthodontic treatment fl Pain medication Sleeping pills Sulfa drugs Tranquilizers Other current medications: Recent exce55ive weight gain Rheumatic fever Shortness of breath Swollen, stiff or painful joints 7 Thyroid problems I I Tonsillectomy (have had) I I Wisdom teeth extraction Other medical history: 2006 TMJ PRACTICE MAAGEMET ASSOCIATES, IC. REPRIT RIGHTS OLY THROUGH LICESIG. Page 3
Family History 1. Have any members of your family (blood kin) had: Yes q o n Heart disease Yes q o n High blood pressure Yes ri o Diabetes 2. Have any immediate family members been diagnosed Yes 111 o 7 or treated for a sleep disorder? Social History Alcohol consumption: How often do you consume alcohol within 2-3 hours of bedtime? q ever q Once a week q Several days a week q Daily [1] Occasionally Sedative consumption: How often do you take sedatives within 2-3 hours of bedtime? q ever q Once a week q Several days a week q Daily q Occasionally Caffeine consumption: How often do you consume caffeine within 2-3 hours of bedtime? q ever q Once a week q Several days a week q Daily [I] Occasionally Do you smoke? q Yes q o If yes, enter the number of packs per day (or other description of quantity): Do you use chewing tobacco? q Yes q o I authorize the release of a full report of examination findings, diagnosis, treatment programs, etc., to any referring or treating dentist or physician. I additionally authorize the release of any medical information to insurance companies or for legal documentation to process claims. I understand that I am responsible for all fees for treatment regardless of insurance coverage. 2006 TMJ PRACTICE MAAGEMET ASSOCIATES, IC REPRIT RIGHTS OLY THROUGH LICESIG. Page 4
THE EPWORTH SLEEPIESS SCALE How likely are you to doze off or fall asleep in the following situations? 4 Check one in each row: Sitting and reading El 2 0 1 Moderate 3 o chance Slight chance chance of High chance of dozing of dozing dozing of dozing Watching TV Sitting inactive in a public q place (e.g. a theater or a meeting) 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 El Sitting quietly after a lunch q 111 without alcohol In a car, while stopped for a q few minutes in traffic Total Score: (Add columns 0-3) 2006 TMJ PRACTICE MAAGEMET ASSOCIATES, IC. 1.800.879.6468. REPRIT RIGHTS OLY THROUGH LICESIG. Epworth