Patient Intake Form

To help us provide the best care, please complete your patient intake forms before your visit. This allows us to prepare for your appointment and ensures a smooth experience from start to finish.

New Patient Registration

Please note, all fields are required for better evaluation.

Full Name:

Today's Date:

Address:

Email Address:

Phone Number:

Date of Birth:

Gender:

Preferred Pronouns:

Occupation:

Employment Status:

How did you hear about our office?

Present Dentist Name:

Present Dentist Location/City:

Present Dentist Phone Number:

Present Primary Care Physician:

Present Primary Care Physician Location/City:

Primary Care Physician Phone Number:

Medical Health Insurance Information

Medical Insurance Company:

Medical Insurance Company ID#:

Medical Insurance Company Group #:

Records Release

I hereby authorize the Snoring and Sleep Apnea Dental Treatment Center to release my information, including diagnosis and records of treatment, concerning my past medical history to my referring physician/dentist or other health care providers, insurance company and immediate family.

I agree to the release of records

Initial Evaluation Questionnaire

Please note, all(*) fields are required.

Have you been told that you snore?*

How long have you been aware of your snoring?*

YesNo

Do you have any difficulty falling asleep at night?*YesNo

Do you have any difficulty staying asleep?*YesNo

How many times per night do you wake up?*

On average, how long does it take to fall back to sleep?*

How would you rate your quality of sleep?*GoodFairPoor

How many hours of sleep do you get per night?*

Do you drink caffeinated beverages?*

If yes, what type of caffeine, and how many cups per day?

YesNo

Do you drink alcohol?*

If yes, how much alcohol do you drink?

YesNo

Do you use tobacco?*

If yes, what type of tobacco do you use and how often?

YesNo

Do you exercise regularly?*

How often do you exercise?

YesNo

What type of exercise?

Current Weight:*

Current Height:*

Have you lost or gained any weight in the last 3 years?*

If yes, how much weight have you gained or lost?

YesNo

Have you had a sleep study?*

If yes, when and where was the study completed?

YesNo

What treatment recommendations were given to you?*

Are you currently using a CPAP?*

Have you tried CPAP previously?*

YesNo

If yes, why did you stop using CPAP?

What is your goal for treatment?*

The Epworth Sleepiness Scale

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 to choose the most appropriate number for each situation.

Sitting and reading*

Watching TV*

Sitting, inactive in a public place (e.g. theater or meeting)*

As a passenger in a car for an hour without a break*

Lying down to rest in the afternoon when circumstances permit*

Sitting and talking to someone*

Sitting quietly after lunch without alcohol*

In a car, while stopped for a few minutes in the traffic*

Thank you! Your submission has been received!

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Patient Intake Form

New Patient Registration

Medical Health Insurance Information

Records Release

Initial Evaluation Questionnaire

The Epworth Sleepiness Scale

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