Sleep Solutions Intake Form

Name *

First

Last

Street Address, City, & Zip *

Home Phone

Cell Phone

Work Phone

Emergency Contact (First & Last Name)

Emergency Contact Phone #

Email *

Age

Date of Birth

Gender

Male
Female

Select the main reason(s) you are seeking treatment for snoring or sleep apnea

If you answered "Other", please enter information here:

If you have participated in a sleep study, where and when

Have you tried CPAP?

Yes
No

Are you currently using CPAP?

Yes
No

If you are currently using CPAP, how many nights per week?

If you are currently using CPAP, how many hours per night do you wear it?

What are your chief complaints about using CPAP:

If you answered "Other", please enter information here:

Are you currently wearing a dental device?

Yes
No

Have you previously tried a dental device?

Yes
No

If yes, what dentist fabricated the device or was it over the counter (OTC)?

Describe your experience with your previous dental device

Rate your overall energy level (1 = Low, 10 = Excellent)

Selected Value: 1

Rate your sleep quality (1 = Low, 10 = Excellent)

Selected Value: 0

Have you been told you snore?

Yes
No
Sometimes

Rate the sound level of your snoring (1 = Quite, 10 = Loud)

Selected Value: 0

On average, how many times per night do you wake up?

On average, how many hours of sleep do you get per night?

How often do you awaken with headaches?

Do you have a bed partner?

Yes
No
Sometimes

Do you sleep in the same room?

Yes
No

What do you do if you cannot sleep?

Do you take sleep aids or supplements?

Who is your primary care physician?

List nose, palatal, throat, tongue, or jaw surgeries you have had:

Date, Surgeon & Surgery Type

Comment about any other therapy attempts (weight loss, gastric bypass, etc.) and how each has impacted your snoring, apnea and sleep quality

If you have been told you need pre-medications before dental procedures, list the medications and why

List medication allergies including latex

List all medications you are currently taking

List all medical diagnoses from birth until now (example: heart attack, high blood pressure, asthma, stroke, hip replacement, AIDS, diabetes, etc.

Have genetic members of your family had (check all that apply)

Heart Disease
High Blood Pressure
Diabetes
Been diagnosed with a sleep disorder

Do you smoke, vape, or use chewing tobacco?

If yes, enter what type

If you smoke, vape or use chewing tobacco, how often?

How often do you consume alcohol within 2-3 hours of bedtime?

Daily
Occasionally
Rarely/Never

How often do you take a sedative within 2-3 hours of bedtime?

Daily
Occasionally
Rarely/Never

How often do you consume caffeine within 2-3 hours of bedtime?

Daily
Occasionally
Rarely/Never

Who referred you here? How did you hear about our office?

I certify that the information I have completed on these forms is true, accurate, and complete to the best of my knowledge. (Fill in Name and Today's Date)