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Home
About
About
Our Philosophy
Oral Medicine Explained
Team
Team
Oral Medicine Specialists
Dentists
Clinical Staff
Psychologists
Physiotherapists
Administrative Staff
Services
Services
Oral Diseases and Disorders
Oral Ulcers
Altered Sensations of the Mouth
Oral Lumps
Oral Cancer
White and red lesions
Oral Dryness
Orofacial Pain and Temporomandibular Disorders
Temporomandibular joint (TMJ) pain
Temporomandibular Joint (TMJ) Noises
Jaw Locking
Clenching and Grinding (Bruxism)
Headaches
Phantom and Persistent Tooth Pain
Trigeminal Neuralgia
Facial Fullness
FAQs
Oral Appliances for Snoring and Sleep Apnoea
Snoring
Obstructive Sleep Apnoea
Mandibular advancement appliance
Sleep Apnoea Screening Test
FAQ
Patients
Patients
Your First Visit
Forms
Orofacial Pain and Dysfunction form
Oral Diseases and Disorders form
Snoring and Sleep Apnoea form
Insurance & Payment Options
Instructional Videos
Sleep Videos
Oral Videos
Pain Videos
News
FAQ
Telehealth for Regional Patients
For Referrers
For Referrers
Refer a patient
Perth Oral Medicine Study Club
Tongue & Cheek Newsletter
Upcoming & Past Events
Hot Topics in Oral Medicine
Contemporary Oral Medicine
OralMedMate
Contact
Contact
West Leederville
Jandakot
Padbury
Midland
Home
Home
About
About
Our Philosophy
Oral Medicine Explained
Team
Team
Oral Medicine Specialists
Dentists
Clinical Staff
Psychologists
Physiotherapists
Administrative Staff
Services
Services
Oral Diseases and Disorders
Oral Ulcers
Altered Sensations of the Mouth
Oral Lumps
Oral Cancer
White and red lesions
Oral Dryness
Orofacial Pain and Temporomandibular Disorders
Temporomandibular joint (TMJ) pain
Temporomandibular Joint (TMJ) Noises
Jaw Locking
Clenching and Grinding (Bruxism)
Headaches
Phantom and Persistent Tooth Pain
Trigeminal Neuralgia
Facial Fullness
FAQs
Oral Appliances for Snoring and Sleep Apnoea
Snoring
Obstructive Sleep Apnoea
Mandibular advancement appliance
Sleep Apnoea Screening Test
FAQ
Patients
Patients
Your First Visit
Forms
Orofacial Pain and Dysfunction form
Oral Diseases and Disorders form
Snoring and Sleep Apnoea form
Insurance & Payment Options
Instructional Videos
Sleep Videos
Oral Videos
Pain Videos
News
FAQ
Telehealth for Regional Patients
For Referrers
For Referrers
Refer a patient
Perth Oral Medicine Study Club
Tongue & Cheek Newsletter
Upcoming & Past Events
Hot Topics in Oral Medicine
Contemporary Oral Medicine
OralMedMate
Contact
Contact
West Leederville
Jandakot
Padbury
Midland
(08) 9376 6798
admin@pomds.com.au
Mon-Fri: 8.30am – 4.30pm
(08) 9376 6798
Phone Number
admin@pomds.com.au
Email Address
Mon-Fri: 8.30am – 4.30pm
Opening Hours
Home
Home
About
About
Our Philosophy
Oral Medicine Explained
Team
Team
Oral Medicine Specialists
Dentists
Clinical Staff
Psychologists
Physiotherapists
Administrative Staff
Services
Services
Oral Diseases and Disorders
Oral Ulcers
Altered Sensations of the Mouth
Oral Lumps
Oral Cancer
White and red lesions
Oral Dryness
Orofacial Pain and Temporomandibular Disorders
Temporomandibular joint (TMJ) pain
Temporomandibular Joint (TMJ) Noises
Jaw Locking
Clenching and Grinding (Bruxism)
Headaches
Phantom and Persistent Tooth Pain
Trigeminal Neuralgia
Facial Fullness
FAQs
Oral Appliances for Snoring and Sleep Apnoea
Snoring
Obstructive Sleep Apnoea
Mandibular advancement appliance
Sleep Apnoea Screening Test
FAQ
Patients
Patients
Your First Visit
Forms
Orofacial Pain and Dysfunction form
Oral Diseases and Disorders form
Snoring and Sleep Apnoea form
Insurance & Payment Options
Instructional Videos
Sleep Videos
Oral Videos
Pain Videos
News
FAQ
Telehealth for Regional Patients
For Referrers
For Referrers
Refer a patient
Perth Oral Medicine Study Club
Tongue & Cheek Newsletter
Upcoming & Past Events
Hot Topics in Oral Medicine
Contemporary Oral Medicine
OralMedMate
Contact
Contact
West Leederville
Jandakot
Padbury
Midland
Snoring and Sleep Apnoea form
Home
Snoring and Sleep Apnoea form
You can
download form as
PDF and send to
forms@pomds.com.au
Title
- Select -
Dr
Mr
Mrs
Ms
Miss
Surname
*
First Name
*
Occupation
Date of Birth
*
Date Format: DD slash MM slash YYYY
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
Date Format: MM slash DD slash YYYY
HCC/Pensioner
Exp
Date Format: MM slash DD slash YYYY
Department of Veteran Affairs
Colour
Exp
Date Format: MM slash DD slash YYYY
Private Health
*
Yes
No
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
Date Format: MM slash DD slash YYYY
(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?
- Select -
Yes
No
Details
Are you a past smoker? If so, how many did you smoke and for how many years? When did you stop smoking?
*
- Select -
Yes
No
Details
Do you drink alcohol on a regular basis? If so, how many per day, and for how many years?
*
- Select -
Yes
No
Details
Do you drink coffee, tea or cola? If yes, how much?
*
- Select -
Yes
No
Details
Do you or have you used recreational drugs? If so, please specify.
*
- Select -
Yes
No
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?
*
Weight loss
Medication
Chin straps
Changing sleep position
CPAP/BiPAP Machine
Nasal spray
Changing pillows
Provent
Breathe-Rite strips
Cut back smoking
Nasal surgery
Oral/dental appliance
Cut back alcohol
Throat surgery
Cut back caffeine
Jaw surgery
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?
*
0- Don’t snore at all
1
2
3
4
5
6
7
8
9
10
Extremely loud - 10
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:
*
0- very mild
1
2
3
4
5
6
7
8
9
10
very severe - 10
c. Pain in the jaw muscles?
*
No
Yes If yes, which side?
Right
Left
Both
Severity of pain:
*
0- very mild
1
2
3
4
5
6
7
8
9
10
very severe - 10
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