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Patient's Email Address:
City, Province, Postal Code:
How did you hear about our Clinic or who may we thank for referring you to our Clinic?
Have you been diagnosed with sleep apnea?
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.
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.
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
Do you wear a CPAP device successfully during sleep?
Have your tried other therapies for your sleeping disorder
Please list other therapies (Weight-loss attempts, smoking cessation, surgeries, etc.)
Other CPAP difficulty:
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.
1. Do you witness the patient snoring?
2. Do you witness the patient choking or gasping for breath during sleep?
3. Does the patient pause or stop breathing during sleep?
4. Does the patient fall asleep easily, if given the opportunity, during the day (normal wakeful hours)?
5. Do you witness the patient clenching and/or grinding his/her teeth during sleep?
6. Does the patient appear refreshed upon waking?
7. Does the patient’s sleep habits disturb your sleep?
8. Does the patient sit up in bed, not awake?
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:
Partner additional comments
CHOICE OF LOCATION:
Windsor - TuesWindsor - Thurs
Leamington - WedAny Location
REASON FOR VISITING:
Snoring & ApneaDenturesOther