Patient Information. WHAT ARE THE CHIEF COMPLAINTS FOR WHICH YOU ARE SEEKING TREATMENT? Please number the complaints with #1 being the most important.
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1 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 TODA'S DATE: MR. MRS. MS DR. MISS AME: FIRST MIDDLE IITIAL LAST AGE: BIRTH DATE Male Female CIT/STATE/ZIP: HOW LOG AT CURRET ADDRESS? PREVIOUS EMPLOED B: (IF LESS THA THREE EARS, PLEASE GIVE PREVIOUS ADDRESS) SS#: HOME PHOE: WORK PHOE: CELL PHOE: RESPOSIBLE PART: FAMIL PHSICIA: FAMIL DETIST: Please list other health care practitioners seen in the last 9 months: ISURACE MEMBER UMBER GROUP UMBER PLA UMBER AME OF PRIMAR CARE PHSICIA HEIGHT: WEIGHT: feet pounds inches REFERRED B: WHAT ARE THE CHIEF COMPLAITS FOR WHICH OU ARE SEEKIG TREATMET? Please number the complaints with #1 being the most important. Frequent heavy sring 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 Other: 2008 TMJ PRACTICE MAAGEMET ASSOCIATES, IC REPRIT RIGHTS OL THROUGH LICESIG. Page 1
2 THE EPWORTH SLEEPIESS SCALE How likely are you to doze off or fall asleep in the following situations? Check one in each row: Sitting and reading 0 1 o chance of dozing Slight chance of dozing 2 Moderate chance of dozing 3 High chance of dozing Watching TV Sitting inactive in a public 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 afteron when circumstances permit Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in traffic Total Score: (Add columns 0-3) 2006 TMJ PRACTICE MAAGEMET ASSOCIATES, IC REPRIT RIGHTS OL THROUGH LICESIG. Epworth
3 Berlin Questionnaire Sleep Evaluation 1. Complete the following: height weight 2. Do you sre? don't kw If you sre: 3. our sring is? age male/female slighly louder than breathing as loud as talking louder than talking very loud. Can be heard in adjacent rooms How often do you feel tired or fatigued after your sleep? During your waketime, do you feel tired, fatigued or t up to par? 4. How often do you sre? 5. Has your sring ever bothered other people? 6. Has anyone ticed that you quit breathing during your sleep? 9. Have you ever dded off or fallen asleep while driving a vehicle? If, how often does it occur? 10. Do you have high blood pressure? don't kw (For office use) 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 Category 2 is positive with 2 or more positive responses to questions 7-9 Category 3 is positive with 1 positive response and/or a BMI>30 (BMI = Body Mass Index) Final Result: 2 or more possible categories indicates a high likelihood of sleep disordered breathing. Berlin
4 Sleep Center Evaluation Have you ever had an evaluation at a Sleep Center? es o If es: Sleep Center ame and Location Sleep Study FOR OFFICE USE OL The evalution confirmed a diagsis of: mild moderate severe obstructive sleep apnea 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 t tolerate it please fill in this section: I could t tolerate the CPAP device due to: Other: mask leaks I was unable to get the mask to fit properly discomfort caused by the straps and headgear disturbed or interrupted sleep caused by the presence of the device ise from the device disturbing my sleep and/or bed partner's sleep CPAP restricted movements during sleep CPAP does t seem to be effective pressure on the upper lip causing tooth related problems a latex allergy claustrophobic associations Other Therapy Attempts an unconscious need to remove the CPAP apparatus at night What other therapies have you had for breathing disorders? (weight-loss attempts, smoking cessation for at least one month, surgeries, etc.) 2008 TMJ PRACTICE MAAGEMET ASSOCIATES, IC. REPRIT RIGHTS OL THROUGH LICESIG. Page 2
5 List any medications which have caused an allergic reaction: Antibiotics Metals Other allergens: Aspirin Penicillin Barbiturates Plastic Codeine Sedatives Iodine Sleeping pills Latex Sulfa drugs Local anesthetics List any medications you are currently taking: Antacids Antibiotics Anticoagulants Antidepressants Anti-inflammatory drugs (n-steroid) Barbiturates Blood thinners Medical History Anemia Arteriosclerosis Asthma Autoimmune disorders Bleeding easily Chronic sinus problems Chronic fatigue Congestive heart failure Current pregnancy Diabetes Difficulty concentrating Dizziness Emphysema Epilepsy Fibromyalgia Frequent sore throats Gastroesophageal Reflux Disease (GERD) Hay fever Heart disorder Heart murmur Heart pounding or beating irregularly during the night Codeine Pain medication Cortisone Sleeping pills Diet pills Sulfa drugs Heart medication Tranquilizers High blood pressure medication Insulin Muscle relaxants Other current medications: erve pills Heart pacemaker Heart valve replacement Heartburn or a sour taste in the mouth at night Hepatitis High blood pressure Immune system disorder Injury to Face Head Insomnia Irregular heart beat Jaw joint surgery Low blood pressure Memory loss Migraines eck Mouth Morning dry mouth Muscle spasms or cramps eeding extra pillows to help breathing at night ighttime sweating Teeth Osteoarthritis Osteoporosis Other medical history: Poor circulation Prior orthodontic treatment Recent excessive weight gain Rheumatic fever Shortness of breath Swollen, stiff or painful joints Thyroid problems Tonsillectomy (have had) Wisdom teeth extraction 2008 TMJ PRACTICE MAAGEMET ASSOCIATES, IC. REPRIT RIGHTS OL THROUGH LICESIG. Page 3
6 Family History 1. Have any members of your family (blood kin) had: es o Heart disease es o High blood pressure es o Diabetes 2. Have any immediate family members been diagsed or treated for a sleep disorder? es o Social History Alcohol consumption: How often do you consume alcohol within 2-3 hours of bedtime? ever Once a week Several days a week Daily Occasionally Sedative consumption: How often do you take sedatives within 2-3 hours of bedtime? ever Once a week Several days a week Daily Occasionally Caffeine consumption: How often do you consume caffeine within 2-3 hours of bedtime? ever Once a week Several days a week Daily Occasionally Do you smoke? es o If, enter the number of packs per day (or other description of quantity): Do you use chewing tobacco? es o I authorize the release of a full report of examination findings, diagsis, 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 TMJ PRACTICE MAAGEMET ASSOCIATES, IC. REPRIT RIGHTS OL THROUGH LICESIG. Page 4
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