GREENVILLE DENTAL SLEEP CENTER, LLC WILLIAM E. WILLIAMS, DDS MARK D. PABST, DDS 2799 South Charles Blvd. Greenville, NC

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1 GREENVILLE DENTAL SLEEP CENTER, LLC WILLIAM E. WILLIAMS, DDS MARK D. PABST, DDS 2799 South Charles Blvd. Greenville, NC Dear Valued Patient, Welcome to the Greenville Dental Sleep Center. We look forward to helping you move toward better health with Oral Appliance Therapy (OAT). DENTAL SLEEP MEDICINE is the study and treatment of Sleep Disordered Breathing, which includes Snoring and Obstructive Sleep Apnea (OSA). These are conditions where normal breathing is disrupted during sleep, resulting in poor sleep quality, daytime sleepiness, and other medical concerns. With the help of your Sleep Physician we can fabricate an Oral Appliance to stop Snoring and open the airway in certain patients with Obstructive Sleep Apnea. Enclosed in your New Patient packet is the following: Patient Information Sheet Health History Acknowledgement and Release Epworth Sleepiness Scale Thornton Snoring Scale Sleep Apnea Quality of Life Index (Before Only) Please fill out the above as accurately as possible. At your first visit we will review the above forms and determine if you are a candidate for Oral Appliance Therapy with a thorough dental exam. We look forward to seeing you soon! Sincerely, William E. Williams, DDS Mark D. Pabst, DDS

2 GREENVILLE DENTAL SLEEP CENTER, LLC WILLIAM E. WILLIAMS, DDS MARK D. PABST, DDS 2799 SOUTH CHARLES STREET PHONE FAX Greenville, NC MEMBERS, AMERICAN ACADEMY OF DENTAL SLEEP MEDICINE Name: Date of Birth / / Address: City/State/Zip: Social Security No. Best Contact Phone: (H C W ): This information will not be shared Sleep Physician: Phone: General Physician: Phone: Dentist: Other : Phone: Phone: CONCERNS What Prompted You to Seek Diagnosis and Treatment? Sleep Apnea Snoring Alternative to CPAP Any Use of Oral Appliance Y N Temporary/Trial Jaw Joint Problems? None Pain Limitations: Any Dental Treatments Recommended? Other Dental Concerns: Any Other Concerns: Treatment Will Be Successful When: _

3 PLEASE CHECK ANY OF THE FOLLOWING WHICH YOU HAVE HAD OR PRESENTLY HAVE: Heart Disease or Attack Angina Diabetes Epilepsy Artificial Heart Valve Heart Murmur Diabetes in Family Dizzy Spells High Blood Pressure Jaw Joint Pain Hay Fever/Allergies Glaucoma Pacemaker Sinus Trouble Cosmetic Surgery Stroke Cold Sores Numbness or Tingling Sensations Please List Any Allergies To: Latex, Medicines, or Metals: Other Allergies: Tobacco Use: None Other: Please list any medications and/or supplements you are taking on a regular basis: ACKNOWLEDGEMENT AND RELEASE To the best of my knowledge the above information is correct. I will inform this office of any changes. I Consent to the taking of photographs and X-rays before, during, and after treatment and to the use of same by the doctor in scientific presentations or demonstrations. I Consent, for the purposes of collaboration among professionals for my treatment, to sharing with other medical professionals my personal medical information and any results of my examination, as deemed necessary by Dr. William E. Williams. Insurance: We provide services for our patients with the understanding that they are responsible for payment in accordance with our financial agreement. We will prepare and submit forms and reports to assist you in obtaining maximum benefits available, but in no case are treatment recommendations or fees affected by the presence or absence of insurance benefits. I authorize my insurance benefits to be paid directly to the dentist. Collections: In the event the balance becomes more than 45 days overdue, billing may be turned over to an outside collection agency. The responsible party listed above agrees to pay interest, collection and other legal expenses related to collection of fees owed. Waiver of any breach of any time or condition shall not constitute a waiver of any further term or condition. Signature Date

4 PATIENT S NAME EPWORTH SLEEPINESS SCALE In contrast to just feeling tired, how likely are you to doze off or fall asleep in the following situations? Use the following scale to choose the most appropriate number for each situation: 0 = Would never doze 1 = Slight chance of dozing 2 = Moderate chance of dozing Date 3 = High chance of dozing BEFORE AFTER SITUATION THERAPY THERAPY Sitting and reading Watching Television Sitting inactive in a public place (i.e. theater) As a car passenger for an hour without a break Lying down to rest in the afternoon Sitting and talking to someone _ Sitting quietly after lunch without alcohol _ In a car, while stopping for a few minutes in traffic _ TOTAL SCORE _ A score of 6 or greater indicates the possibility of sleep disordered breathing THORNTON SNORING SCALE Snoring has a significant effect on the quality of life for many people. Snoring can affect the person snoring and those around him/her., both physically and emotionally. Use the following scale to choose the most appropriate number for each situation. (Go to question #4 if you have no bed partner.) 0 = Never 1 = Infrequently (1 night per week) 2 = Frequently (2-3 nights per week) 3 = Most of the time (4 or more nights per week) BEFORE AFTER THERAPY THERAPY My snoring affects my relationship with my partner _ My snoring causes my partner to be irritable or tired _ My snoring requires us to sleep in separate rooms _ My snoring is loud _ My snoring affects people when I am sleeping away from home (i.e. hotel, camping, etc.) _ TOTAL SCORE _ A score of 5 or greater indicates your snoring may be significantly affecting your quality of life W. Keith Thornton Epworth - Thornton Scales 1

5 Sleep Apnea Quality of Life Index Before and After therapy Name/Study No Before Date After Date Therapy TAP CPAP Other We would like to understand whether your sleep apnea and/or snoring have had an impact on your daily activities, emotions, social interactions, and about symptoms that may have resulted. PLEASE SCORE THE FOLLOWING QUESTIONS ACCORDING TO THE FOLLOWING: A very large = 1 A large = 2 A moderate to large = 3 A moderate = 4 A small to moderate = 5 A small = 6 No or none = 7 OVER THE PAST 4 WEEKS: 1. How much (amount) have you had to push yourself to remain alert during a typical day (e.g. work,school, childcare, housework)? 2. How have (amount of time) you had to use all your energy to accomplish your must important activity (e.g. work, school, childcare, housework)? 3. How much difficulty (amount) have you had finding the energy to do other activities (e.g. exercise, relaxing)? 4. How much difficulty (amount) have you had fighting to stay awake? 5. How much of a problem has it been to be told that your snoring is irritating? 6. How much of a problem have frequent conflicts or arguments been? 7. How often (amount of time) have you looked for excuses for being tired? 8. How often (amount of time) have you not wanted to do things with your family and/or friends? 9. How often (amount of time) have you felt depressed, down, or hopeless? 10. How often (amount of time) have you been impatient? 11. How much of a problem has it been to cope with everyday issues? 12. How much of a problem have you had with decreased energy? 13. How much of a problem have you had with fatigue? 14. How much of a problem have you had waking up feeling unrefreshed? Before After Total Divide total by 14 SAQLI score

6 SECTION II (If you have not been using treatment for sleep apnea in the past 4 weeks DO NOT complete this section) We would like you to mark below the primary treatment you are currently using for sleep apnea: Treatment: Medication CPAP Dental appliance Weight loss Surgery Other (please specify) (please specify) Next we would like you list up to three side effects you have found most troubling as a result of this treatment please write them in the spaces below. For each side effect please rate how much of a problem it has been for you in the past 4 weeks. Some side effects that people may experience include: nasal stuffiness, dry nose or throat, sore eyes, headache, sore throat, jaw pain, waking up frequently, stomach upset, increased saliva. 15. Side effect 1. How much of a problem have you had with this? no problem a small problem a small to moderate a moderate problem a moderate to large a large problem a very large problem problem problem 16. Side effect 2. How much of a problem have you had with this? no problem a small problem a small to moderate a moderate problem a moderate to large a large problem a very large problem problem problem 17. Side effect 3. How much of a problem have you had with this? no problem a small problem a small to moderate a moderate problem a moderate to large a large problem a very large problem problem problem 18. Considering these side effects please choose the statement that best describes the trade off between side effects and benefits. Overall, compared with the benefits, would you say that the problems with side effects you listed in question were (choose one): no problem a small problem a small to moderate about equal to a moderate to large a large problem a very large problem compared to compared to problem compared to the benefits problem compared to compared to compared to the benefits the benefits the benefits the benefits the benefits the benefits Thank you for your co-operation in completing this questionnaire.