COMPREHENSIVE HEALTH QUESTIONNAIRE
The purpose of this questionnaire is to determine the nature of your health problem. It is very important to be as accurate as possible in answering the questions. Your partner may be able to assist you.
General Information
(This information will become part of your medical record and will remain confidential.)
Patient Name
*
First Name
Middle Name
Last Name
Date
/
Month
/
Day
Year
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
*
Please enter a valid phone number.
Cell Phone Number
*
Please enter a valid phone number.
Work Phone Number
*
Please enter a valid phone number.
May we call you at work?
Yes
Email
*
example@example.com
Best way to reach you
Please Select
Home Phone
Cell Phone
Work Phone
Email
Date of Birth
*
-
Month
-
Day
Year
Date
Age
Height
Weight
Sex
Male
Female
Single
Widowed
Divorced
Married/Partner
SSN
Occupation
Patient Signature
*
Emergency Contact
First Name
Middle Name
Last Name
Relationship
Your relationship with the emergency contact.
Phone Number
Please enter a valid phone number.
List current medical conditions for which you are being treated
List all hospitalizations and surgeries you have had. (Please be thorough and include surgeries to remove your adenoids or tonsils, or hospitalizations for head injury, seizures or heart conditions.)
List medications you are currently taking. (Please include prescription and non-prescription medications of all types, including sleep and non-sleep related. Also indicate if you are on supplemental oxygen.)
Please list any allergies:
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Health Questions
Please answer the best you can
Have you ever sustained a concussion, head injury, or serious blow to the head?
Yes
No
Do you smoke?
Yes
No
Have you quit smoking?
Yes
No
Have you ever been diagnosed with obstructive sleep apnea (OSA) ?
Yes
No
Are you currently being treated for OSA?
Yes
No
Are you aware of a family history of OSA?
Yes
No
Have you experienced a weight gain in the past year?
Yes
No
How much weight?
By how much?
Are you aware of clenching or grinding your teeth at night?
Yes
No
How long has your sleep problem bothered you?
Greater than 2 yrs.
1 - 2 yrs.
Several months
Last 3 months
Within the month
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Sleep Questions
Do you snore loudly?
Please Select
YES
NO
Do you often feel tired, fatigued, or sleepy duting the day?
Please Select
YES
NO
Has anyone observed you stop breathing during your sleep?
Please Select
YES
NO
Do you have or are you being treated for high blood pressure?
Please Select
YES
NO
Is your body mass index higher than 28?
Please Select
YES
NO
Are you 50 years old or older?
Please Select
YES
NO
Male: is your neck size 17'' or greater? Female: 16'' or greater?
Please Select
YES
NO
Are you male?
Please Select
YES
NO
Do you have memory or concentration problems?
Please Select
Never
Rarely
Often
Frequent
Always
Are you a light sleeper, easily awakened?
Please Select
Never
Rarely
Often
Frequent
Always
Does your snoring stop for brief periods during sleep?
Please Select
Never
Rarely
Often
Frequent
Always
Is your bed partner disturbed by your snoring?
Please Select
Never
Rarely
Often
Frequent
Always
Do you wake up choking or gasping for breath?
Please Select
Never
Rarely
Often
Frequent
Always
Do you have heartburn at night?
Please Select
Never
Rarely
Often
Frequent
Always
Do you have nasal / sinus congestion at night?
Please Select
Never
Rarely
Often
Frequent
Always
Do you have morning headaches?
Please Select
Never
Rarely
Often
Frequent
Always
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Dysfunction
Can you move your mouth normally?
Completely
Partially
Do you ever open so wide that your mouth locks open?
Yes
No
Do you have any of these sounds in the joint?
Snapping
Grating
If you have any of these problems, is it frequent?
Yes
No
Miscellaneous And Associated Complaints And Questions
Have you had cortisone injected into a joint?
Yes
No
When?
How many injections?
By whom?
Do you clench your teeth?
Yes
No
Has anyone mentioned that you grind your teeth (brux) at night during sleep?
Yes
No
Have you had any other treatment for this problem?
Yes
No
Explain - medicine, exercise, dental treatment.
Have you had your bite adjusted by your dentist?
Yes
No
When?
Do you chew gum?
Frequently
Moderately
Infrequently
Never
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Submit
Should be Empty: