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Please turn on the switch matching your appointment type
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New Patient Visit or evaluation for new appliance (Sleep/Snore)
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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 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 (required)
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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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Name of Dentist
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Date of your last dental visit?
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Do you have any upcoming dental work?
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Description of upcoming dental work
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Appliance Delivery Appointment
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No questions for you today. You can go to the next portion of the forms.
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Follow up visit after appliance delivery (Sleep/Snore)
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Do you wear your appliance?
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Do you wear it all night long?
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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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Do you snore?
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Adjusted your appliance since the last time at the office?
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Follow up: Comments
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Follow up: Which specialists do you see?
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Have you had an efficacy study recently?
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Has your sleep specialist changed?
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TMJ Visit
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Have you ever been examined for facial pain before?
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If yes, provider name:
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Issues experienced:
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How long have you been experiencing this problem?
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Is this getting better, worse or staying the same?
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Have you ever had physical therapy for TMD?
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If yes, who did you see:
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Have you ever received treatment for jaw problems?
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if yes, who saw you?
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Please select treatments that you have already attempted:
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Current Stress Factors (mark each that apply to you)
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My Current and Previous Habits:
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Comments:
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