Consent Form For Dental Appliance Treatment of Snoring and/or Sleep Apnea
Return to Sleep Disorders Page
Questionnaire For Potential Sleep Appliance Patients
Today's Date
Last Name
First Name
Middle Intl.
Who referred you to this office for a sleep appliance consulltation?
Have you been diagnosed as having a sleep disorder?
Yes No
If so, what?
Have you had an overnight study in a sleep disorders center?
Yes No
If yes, what was the result of the study?
 
Do you have excessive sleepiness in the daytime with your normal activity?
Yes No
While driving?
Yes No
Do you frequently have a headache in the morning?
Yes No
Do you have high blood pressure?
Yes No
If yes, is it being treated?
Yes No
Do you snore?
Yes No
Have you been told you stop breathing during your sleep?
Yes No
How tall are you?   ft.   in.

The following sleepiness scale can be helpful in determing how much sleeping disorder you have. How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Use the following scale to choose the most appropriate number for each situation.

0 = would nver doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Situation
Chance of dozing
Sitting and reading
Watching TV
Sitting, inactive in a public place (theater or movie)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic