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Medical Evaluation

Name:*

Date Of Birth:*

Email:*

Phone number:*

Preferred contact method:

Name of your primary care physician (the doctor responsible for the majority of your medical care):

Name of your dentist:

What caused you to seek evaluation for sleep apnea?

Who did you first see for evaluation?

Please Select “Yes” or “No” to the following questions:

Do you snore?

Yes No

Do you have frequent sore throats?

Yes No

Are you a smoker?

Yes No

Have you ever been told that you stop breathing for periods of time while sleeping?

Yes No

Do you experience daytime sleepiness?

Yes No

Have you ever fallen asleep at work or during social activities?

Yes No

Do you often feel as if your memory and/or judgment is affected?

Yes No

Have you noticed a decrease in sexual desire?

Yes No

Do you feel you are overweight?

Yes No

If so, how long have you been overweight?

1 year 2 years 3+Years

Do you often feel depressed?

Yes No

Have you ever been treated for depression?

Yes No

If so, for how long?

With what medication(s)?

Have you been diagnosed with any of the following medical conditions?

Arrhythmia (Heart Irregularity)

Yes No

Hypertension (High Blood Pressure)

Yes No

Pulmonary Hypertension

Yes No

Polycythemia

Yes No

Asthma

Yes No

Emphysema

Yes No

Neurologic Disorder

Yes No

Thyroid Disorder

Yes No

Have you ever been treated for sleep apnea?

Yes No

If so, which of the following treatments have you tried?

Diet

Yes No

Specify Diet:

Medications

Yes No

Specify Medications:

Mouthpiece

Yes No

Oxygen

Yes No

CPAP

Yes No

Have you ever had any operations for sleep apnea?

Yes No Don't Know

If so, which of the following have you had?

Nasal Surgery

Yes No Don't Know

Tonsillectomy/Adenoidectomy

Yes No Don't Know

Palatoplasty (“UPPP”)

Yes No Don't Know

Glossoplasty (tongue reduction)

Yes No Don't Know

Osteotomy (movement of jaws)

Yes No Don't Know

Name of surgeon(s)

Would you consider having surgery if you felt it would improve your condition?

Yes No

Prior to being referred to us for evaluation, what specialists have you seen for evaluation and/or treatment?

Neurologist

Please specify if evaluation and/or treatment:

Pulmonologist

Please specify if evaluation and/or treatment:

Internist

Please specify if evaluation and/or treatment:

Other

Please specify if evaluation and/or treatment:

Have you been to a “Sleep Lab” for evaluation?

Yes No

Select a date

If you have been to a sleep lab, do you know the results? If so please give a brief summary, in your own words:

Do you remember being given a score called an “RDI”? If so, what was your RDI?