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New Patient Visit
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Do you snore?
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How many hours do you sleep?
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Time you usually go to bed
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Time you usually wake up
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Average hours of sleep per night
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Average awakenings per night
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Usual Sleep position
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I breath through
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Energy Level
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Do you grind your teeth
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CPAP History
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Who referred you?
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Where did you find us?
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Anything special we need to know
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Which specialists do you see?
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Treatment Goals?
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Follow up after appliance delivery
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Do you wear your appliance?
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Do you wear it all night long?
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Follow up: Average Hours sleep per night?
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Wake up how many times per night
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Jaw Pain
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Tooth Pain
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Are you waking up feeling rested?
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Are you dreaming?
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Follow up: Do you snore?
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Have you adjusted your appliance since the last time you were at the office
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Follow up: Anything you would like us to know before your visit
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Follow up: Which specialists do you see?
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Have you had an efficacy study since your last visit
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Has your sleep specialist changed since your last visit here
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