Snoring and Sleep Apnoea form - Perth Oral Medicine & Dental Sleep Centre

Title

Surname*

First Name*

Occupation

Date of Birth*

Address*

Street Address Suburb ZIP / Postal Code

Telephone (M)*

Telephone (H)*

Email Address*

Work Details*

(W)*

Emergency Contact/Next of Kin*

Relationship*

(M)*

(H)*

Medicare No

Ref

Exp

HCC/Pensioner

Exp

Department of Veteran Affairs

Colour

Exp

Private Health*

Insurer Name*

General Practitioner*

Address*

Street Address Suburb ZIP / Postal Code

Dentist*

Address*

Street Address Suburb ZIP / Postal Code

Referred by*

General Practitioner
Dentist
Other (Details below)

Name*

Address*

Street Address Suburb ZIP / Postal Code

For additional health practitioners involved in your care, please complete their details below.

Please Tick YES / NO / DETAILS

Name of Practitioner*

Specialty*

Address*

Street Address Suburb ZIP / Postal Code

I agree to the privacy policy.

Privacy Statement: We value your privacy. All of the information, which you provide to us, will be held and used by us in accordance with our Privacy Policy. A copy of our Privacy Policy is attached to this clipboard. Please take the time to read through our Privacy Policy before answering the Questionnaire and speak to one of our staff members if you have any concerns about how we will use your personal information.
1. Please answer the following questionnaire truthfully and to the best of your ability. If ever your health status or medications change, please inform your practitioner at the next appointment.
2. Practice policy is all accounts are settled on the day, immediately after seeing the practitioner.
3. Please note that Medicare rebates are not available. Rebate for services are only available from Private Health Funds. We do not process Private Health Fund rebates for patients at the rooms.
4. The practitioners are not "preferred providers" of any Private Health Fund and have no control over your rebate received.
5. Patients will be charged for missed and late cancellation appointments unless cancelled 24 hours prior to the consult time. DVA, Workers’ Compensation and Motor Vehicle Accident patients will be charged privately for appointments not kept.
6. Some consultations and procedures may not be claimable under Workers’ Compensation, Third Party or General Insurance. We will assist you in directing your bills to the relevant insurance body/solicitors for settlement. However, you are ultimately responsible
for the account irrespective of any disputes with the insurance companies.
7. Please ensure the above information regarding health practitioners involved in your care is current and complete. Correspondence will be sent to all health practitioners listed unless you advise us otherwise.
8. We would appreciate notification of any change of address.
9. CCTV (video only) operates in these premises for security reasons only and not for patient records.
10. I consent to allow my de-identified clinical information and photographs to be used for educational purposes.

I declare that the particulars and information provided are true and correct, and I understand and agree to the above conditions. Further, I hereby authorise Perth Oral Medicine & Dental Sleep Centre and its practitioners, to obtain and release information about my condition to assist in my treatment and/or rehabilitation.

Patient/Guardian Signature*

Date

(If under 18 years): Guardian Name

Guardian Address

Phone

Do you have a Trust Account or a Third Party that settles your account? If yes, please see Reception.

Do you smoke? If so, how many per day, and for how many years?

Details

Are you a past smoker? If so, how many did you smoke and for how many years? When did you stop smoking?*

Details

Do you drink alcohol on a regular basis? If so, how many per day, and for how many years?*

Details

Do you drink coffee, tea or cola? If yes, how much?*

Details

Do you or have you used recreational drugs? If so, please specify.*

Details

Are you taking any tablets or medicines (prescribed or over-the-counter preparations) at present? If yes, please specify.

Do you have any known allergies (penicillin, drugs, latex, and foods)? If yes, please specify.

Do you have any dental treatment that is ongoing? If yes, please specify.

When was your last appointment with a dentist?

DO YOU HAVE, OR HAVE YOU EVER HAD, ANY OF THE FOLLOWING MEDICAL CONDITIONS? (Please tick)

Heart disease*

Yes
No

Hay fever*

Yes
No

Overweight*

Yes
No

High blood pressure*

Yes
No

Family history of snoring/ sleep apnoea*

Yes
No

Stroke*

Yes
No

Breathing problems*

Yes
No

Depression*

Yes
No

Headache*

Yes
No

Heart burn/reflux*

Yes
No

Anxiety*

Yes
No

Anxiety*

Yes
No

Diabetes*

Yes
No

Cancer*

Yes
No

Claustrophobia*

Yes
No

Do you have any other medical conditions? If yes, please list all other medical conditions.*

Height (cm)*

Weight (kg)*

Collar size*

1. What is your reason for coming to the clinic?*

2. How long have you been bothered by this problem?*

3. Have you had an overnight sleep study?*

No
Yes
At home
In Sleep Centre

When?

Diagnosis*

Snoring
Obstructive Sleep Apnoea
Upper Airway Resistance Syndrome

4. What is your predominant sleeping position?*

Back
Side
Stomach

5. Is your mouth open while sleeping?*

No
Yes

6. What previous treatment(s) have you tried to correct your problems?*

7. How many hours of sleep do you average a night? _____ hours*

8. Do you do shift work?*

No
Yes

9. According to your bed partner or other witness, how loud is your snoring?*

10. According to your bed partner or another witness, do you have times when you suddenly stop snoring and then “gasp and snort”?*

Never
Occasionally
25% of times
50% of times
75% of times
Most times

11. How do you usually feel in the morning when you awaken?*

Refreshed or
Unrefreshed:
Mildly
Moderately
Severely

12. Do you awaken in the morning with a headache?*

No
Yes

If yes, how often?*

<1 time/week
1-2 times/week 3
-4 times/week
Most mornings

13. Lethargy (as distinct from sleepiness) may be described as an abnormal lack of energy, mental fatigue, tiredness of mind, a feeling of being “worn out” mentally, mental slowness and dullness. On most days, how would you describe your feeling of lethargy?*

Nil
Mild
Moderate
Severe

14. Do you have a daytime nap in bed or on a couch?*

No
Yes

If yes, how long for?*

If yes, how often?*

1-2 times/month
1-2 times/week
3-4 times/week
Most days

15. In sedentary circumstances (eg sitting, reading, watching TV) during the day, how often do you feel drowsy or fall asleep?*

Never
Occasionally
25% of times
50% of times
75% of times
Most times

16. In sedentary circumstances (eg sitting, reading, watching TV) in the evenings, how often do you feel drowsy or fall asleep?*

Never
Occasionally
25% of times
50% of times
75% of times
Most times

17. How long can you drive during the day, before you feel sleepy? _____ hours*

18. Do you have any concerns about your memory?*

No
Yes

19. Are you able to concentrate?*

No
Yes

20. Do you consider your mood to be depressed?*

No
Yes

21. In general, is your motivation reduced?*

No
Yes

22. In the following situations, indicate how likely you are to doze off or fall asleep in contrast to just being tired. This refers to your usual way of life at this time. Use the following scale to choose the most appropriate number for each situation.
0 = never fall asleep 1 = slight chance of falling asleep 2 = moderate chance of falling asleep 3 = high chance of falling asleep

Sitting or reading*

0
1
2
3

Watching TV*

0
1
2
3

Sitting, inactive in a public place (theatre or movie)*

0
1
2
3

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

0
1
2
3

Lying down to rest in the afternoon*

0
1
2
3

Sitting and talking to someone*

0
1
2
3

Sitting quietly after lunch without alcohol*

0
1
2
3

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

0
1
2
3

Total*

23. Are you aware of, or have you been told that you grind or clench your teeth during sleep?*

No
Yes

24. Have you ever used, or been told, you need a biteguard for teeth grinding or clenching?*

No
Yes

25. Do you experience any of the following:

a. Sounds in the jaw joints?*

No
Yes If yes, which side?
Right
Left
Both

b. Pain in the jaw joints?*

No
Yes If yes, which side?
Right
Left
Both

Severity of pain:*

c. Pain in the jaw muscles?*

No
Yes If yes, which side?
Right
Left
Both

Severity of pain:*

d. Difficulty opening your mouth normally?*

No
Yes

e. Pain preventing you from opening your mouth normally?*

No
Yes

f. Do you feel that there is a physical blockage in the joint that prevents you from opening your mouth normally?*

No
Yes

g. Painful or sore teeth?*

No
Yes

h. Loose teeth?*

No
Yes

i. Dry mouth?*

No
Yes