Sleep Apnea Forms

Simply Fill Out & Submit The Form Below

Or Click The Button To Download The Forms

SLEEP PATIENT INFORMATION


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MARRIEDSINGLEDIVORCEDWIDOWEDCOMMON LAW






FEMALEMALE








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EXTENDED HEALTH INSURANCE INFORMATION

We will gladly provide you with insurance pre-determinations, claims and any necessary information for each visit. Depending on the insurance company we may, or may not be permitted to take assignment of benefits. Please let us know if you have any questions.

PRIMARY INSURANCE

SECONDARY INSURANCE

PATIENT MEDICAL INFORMATION

To better coordinate your treatment, please list the professionals you have consulted regarding your present symptoms. Please be sure to list your primary Physician and family Dentist.

Family Doctor/Physician



Dentist



Cardiologist/Internest



Other Health Practitioner



Please List ALL Current Medications:
Have You Been Treated With Any Of The Following::
Diabetes
Respiratory Disease (Asthma)
Epilepsy
Allergies
Hepatitis
Contagious Disease
High Blood Pressure
Heart Problems
HIV
Rheumatic Fever
Stroke
Other
Additonal Information:
Have you gained or lost weight recently?
Do you have pain and/or clicking in your jaw?
Do you have ringing in your ears?
Do you suffer from frequent headaches?
Do you have sensitive or painful natural teeth??
Do your gums feel tender or sore?
Any lumps or sore spots in your mouth?
Do you smoke?

THIS SECTION IS TO BE FILLED OUT BY THE PATIENT

How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired?
This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you.

Use the following scale and choose the most appropriate number for each situation:

0 = Would never doze

1 = Slight chance of dozing

2 = Moderate chance of dozing

3 = High chance of dozing

Additonal Information:
Have you gained or lost weight recently?
Do you have pain and/or clicking in your jaw?
Do you have ringing in your ears?
Do you suffer from frequent headaches?
Do you have sensitive or painful natural teeth?
Do your gums feel tender or sore?
Any lumps or sore spots in your mouth?

IF YOU HAVE NOT WORN A CPAP DEVICE, SKIP THIS SECTION

CPAP HISTORY


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If you are unable to wear a CPAP device, please check below the reasons for your difficulty.
Mask Leaks
Mask Uncomfortable/Device Uncomfortable
Unable to sleep comfortably
Noise disturbs my sleep and/or bed partner’s sleep
Restricts movement during sleep
Does not seem to be effective
Straps/Headgear cause discomfort
Pressure on the upper lip causes tooth related problems
Latex Allergy
Claustrophobia
Other


THIS SECTION IS TO BE FILLED OUT BY THE PATIENT'S SLEEP PARTNER (IF AVAILABLE)

Sleep Partner's Survey

To help us with a proper diagnosis and appropriate treatment plan, have your bed partner, if applicable, fill out this questionnaire regarding YOUR sleep habits. This information is vitally important for Patrick Strong to best evaluate your current condition.



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YesNo


YesNo


YesNo


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Please check the sleep habits of the patient that are disturbing to you:
Snores
Stops braething
Loud gasping for breath
Kicking during sleep
Sleep talking
Wakes up often
Restless
Grinds teeth
Sleep walking
Biting tongue
Other

How likely is your partner to doze off or fall asleep in the following situations, in contrast to just feeling tired?

This refers to daily life in recent times, if these things have not occurred recently, try to work out how they would have affected your partner. Use the following scale and choose the most appropriate number for each situation:

Use the following scale and choose the most appropriate number for each situation:

0 = Would never doze

1 = Slight chance of dozing

2 = Moderate chance of dozing

3 = High chance of dozing