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 time and answer each question as completely and honestly as possible. Please sign each page. Patient Information TODAYSDATE: DMR. OMS o MISS NAME: o MRS. o DR. FIRST AGE: BIRTH DATE ADDRESS: CITYISTATEIZIP: ---------------- MIDDLE INITIAL o Male 0 Female HOW LONG AT CURRENT ADDRESS? (IF LESS THAN THREE YEARS, PLEASE GIVE PREVIOUS ADDRESS) PREVIOUS ADDRESS: EMPLOYED BY: ADDRESS: SS#: HOME PHONE: WORK PHONE: CELL PHONE: RESPONSIBLE PARTY: FAMILY PHYSICIAN: EMAIL: ADDRESS: ~~ ~~-~------ FAMILY DENTIST: ADDRESS: Please list other health care practitioners seen in the last 9 months: last INSURANCE MEMBER NUMBER GROUP NUMBER PLAN NUMBER NAME OF PRIMARY CARE PHYSICIAN HEIGHT: feet inches WEIGHT: pounds REFERRED BY: WHAT ARE THE CHIEF COMPLAINTS FOR WHICH YOU ARE SEEKING TREATMENT? Please number the complaints with '1 being the most. Important. Frequent heavy snoring _ which affects the sleep of others Significant daytime drowsiness I have been told that "/ stop breathing" when sleeping. Difficulty falling asleep Gasping when waking up Nighttime choking spells Feeling unrefreshed in the morning Morning hoarseness Morning headaches Swelling in ankles or feet Nocturnal teeth grinding Jaw pain Faci8J pain Jaw clicking, Other: Patient Signature Date @ 200B TMl PRACTICE MANAGEMENT ASSOCIATES, INC. 1.800.879.6468. REPRINT ROHTS ONLY THROUGH LICENSING. Page 1
Sleep Center Evaluation Have you ever had an evaluation at a Sleep Center? 0 Yes o No If Yes: Sleep Center Name and Location Sleep Study Date FOR OFFICE USE ONLY o mild The evalution confirmed a diagnosis of: 0 moderate obstructive sleep apnea o severe The evaluation showed an RDI of and an AHI of CPAP Intolerance (Continuous Positive Airway Pressure device) If you have attempted treatment with acpap device, but could not tolerate it please fill in this section: I could not tolerate the CPAP device due to: o mask leaks o I was unable to get the mask to fit properly o discomfort caused by the straps and headgear o disturbed or interrupted sleep caused by the presence of the device o noise from the device disturbing my sleep and/or bed partner's sleep o CPAP restricted movements during sleep o CPAP does not seem to be effective o pressure on the upper lip causing tooth related problems o a latex allergy o claustrophobic associations o 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.} Patient Signature -'-- - Date @ 2008 TMJ PRACTICE MANAGEMENT ASSOCIATES, INC. REPRINT RIGHTS ONLV THROUGH LICENSING. Page 2
List any medications which have caused an allergic reaction: yo NO Antibiotics yo NO Aspirin yo NO Barbiturates YO NO Codeine YO NO Iodine YO NO Latex YO NO Local anesthetics yo NO Metals yo NO Penicillin yo NO Plastic yo NO Sedatives YO NO Sleeping pills yo NO Sulfa drugs Other allergens: List any medications you are currently taking: yo NO Antacids yo NO Codeine yo NO Antibiotics yo NO Cortisone YO NO Anticoagulants yo NO Diet pills YO NO Antidepressants yo NO Heart medication yo NO Anti-inflammatory drugs (non-steroid) yo NO Insulin yo NO Barbiturates yo NO Muscle relaxants yo NO Blood thinners yo NO Nerve pills Medical History YO NO Anemia yo NO Heart pacemaker YO NO Arteriosclerosis YO NO Asthma yo NO Autoimmune disorders YO NO Bleeding easily yo NO 9hronic sinus problems yo NO Chronic fatigue YO NO Congestive heart failure yo NO Current pregnancy yo NO Diabetes yo NO Difficulty concentrating yo NO Dizziness YO NO Emphysema yo NO Epilepsy yo NO Pain medication yo NO Sleeping pills yo NO Sulfa drugs yo NO Tranquilizers yo NO High blood pressure medication yo NO Fibromyalgia yo NO Memory loss YO NO Frequent sore throats yo NO Migraines yo NO Gastroesophageal Reflux yo NO Morning dry mouth Disease (GE,RD) yo 'v[] NO Hayfever NO Muscle spasms or cramps yo NO Heart disorder 't'[] NO Needing extra pillows to YO NO Heart murmur help breathing at night yo NO Heart pounding or beating YO NO Nighttime sweating irregularly during the night Other current medications: yo NO Osteoarthritis YO NO Heart valve replacement YO NO Osteoporosis yo NO Heartburn or a sour taste yo NO Poor circulation in the mouth at night yo NO Prior orthodontic treatment yo NO Hepatitis YO NO High blood pressure yo NO Immune system disorder YO NO Injury to Face o Neck o Head YO NO Insomnia " yo NO Irregular heart beat yo NO Jaw joint surgery o Mouth 0 Teeth yo NO Low blood pressure yo NO Recent excessiv~ weight gain yo NO Rheumatic fever yo NO Shortness of breath YO NO Swollen, stiff or painful joints YO NO Thyroid problems yo NO Tonsillectomy (have had) yo NO Wisdom teeth extraction Other medical history: Patient Signature " Date 2008 TMJ PRACTK;E MANAGEMENT ASSOCIATES, INC. REPRINT RK3HTS ONLY THROUGH LICENSING. Page 3
Family History 1. Have any members of your family (blood kin) had: YesD NoD Heart disease YesD NoD High blood pressure YesD NoD Diabetes 2. Have any immediate family members been diagnosed Yes D No D or treated for a sleep disorder? Social History Alcohol consumption: How often do you consume alcohol within 2-3 hours of bedtime? D Never D Once a week D Several days a week D Daily 0 Occasionally Sedative consumption: How often do you take sedatives within 2-3 hours of bedtime? D Never D Once a week D Several days a week D Daily D Occasionally Caffeine consumption: How often do you consume caffeine within 2-3 hours of bedtime? D Never D Once a week D Several days a week 0 Daily 0 Occasionally Do you smoke? DYes D No If yes, enter the number of packs per day (or other description of quantity): Do you use chewing tobacco? DYes D No 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. Patient Signature Date 2008 TMJ PRACTICE MANAGEMENT ASSOCIATES. INC. REPRINT RIGHTS ONLY THROUGH LICENSING. Page 4
Serlin Questionnaire Sleep Evaluation 1. Complete the following: 7. How often do you feel tired or fatigued after N your sleep? height age C o weight malelfemale 0) 0 nearly every day.ly ro u 0 3-4 times a week 2. Do you snore? 1-2 times a week Dyes 1-2 times a month o never or nearly never o no o don't know /fyou snore: 8. During your waketime, do you feel tired, fatigued or not up to par? 3. Your snoring is? nearly every day slighly louder than breathing 3-4 times a week as loud as talking o 1-2 times a week louder than talking 1-2 times a month o very loud. Can be heard in adjacent rooms o never or nearly never 4. How often do you snore? 9. Have you ever nodded off or fallen asleep while driving a vehicle? 0 nearly every day. 0 3-4 times a week Dyes I 1-2 times a week o no o 1-2 times a month If yes, how often does it occur? o never or nearly never 5. Has your snoring ever bothered other people? nearly every day o 3-4 times a week yes I 1-2 times a week o no 1-2 times a month 6. Has anyone noticed that you quit breathing o never or nearly never during your sleep? o nearly every day o 3-4 times a week ' 0 yes 0) o 1-2 times a week.ly 0 no o 1-2 times a month B D don't know o never or nearly never (For office use) (T) 10. Do you have high blood pressure? Scoring Questions: Any answer within the box outline is a positive response Scoring categories: Category 1 is positive with 2 or more positive responses to questions 2-6 0 Category 2 is positive with 2 or more positive responses to questions 7-9 0 Category 3 is positive with 1 positive response and/or a BMI>30 0 Final Result: 2 or more possible categories indicates a high likelihood of sleep disordered breathing... I,...(-BM-I-;;;-Bo-dy-M~a-SS-I-nd-e--,X)! Patient Signature Date Berlin
THE EPWORTH SLEEPINESS SCALE How likely are you to doze off or fall asleep in the following situations?..j Check one in each row: 0 1 2 Moderate 3 Slight chance chance of of dozing dozing No chance of dozing Sitting and reading 0 0 0 0 Watching TV 0 0 0 0 Sitting inactive in a public 0 0 0 0 place (e.g. a theater or a meeting) As a passenger in a car 0 0 0 0 for an hour without a break Lying down to rest in the 0 0 0 0 afternoon when circumstances permit Sitting and talking to someone 0 0 0 0 Sitting quietly after a lunch 0 0 0 0 without alcohol In a car, while stopped for a 0 0 0 0 few minutes in traffic High chance of dozing Total Score: (Add columns 0-3) Patient Signature Date 2006 TMJ PRACTICE ~AGEMENT ASSOCIATES. INC. 1.800.879.6468. REPRINT RIGHTS ONt. V THROUGH LICENSING. Epworth