Sleep Apnea Questionnaire

Name*

First NameLast Name

Height*

Weight*

DOB*

DOB

Age*

Male or Female*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired?*

	I would never doze	I have a slight chance of dozing	I have a moderate chance of dozing	I have a high chance of dozing
While sitting or reading ?
Watching TV
Sitting inactive in a public place (theater or meeting)
As a passenger in a car for an hour without a break?

Diagnosed or Treated*

History of StrokeMood DisordersInsomniaHypertension (high blood pressure)Impaired Cognition (i.e., difficulty concentrating or thinking)Ischemic Heart Disease (Coronary Artery Disease/Atherosclerosis)Obstructive Sleep Apnea (OSA), If yes did you try to use a CPAPGastric Reflux (GERD) or HeartburnNone of the Above

Are you completing this form for yourself or your child?*

Are you aware of (or have you been told):

	YES	No	Not Sure
Snoring on a regular basis
Feeling tired or fatigued on a regular basis
Clenching or grinding your teeth (bruxism
Having frequent headaches
Your neck size being > 17 inches (male) or > 16 (female)
Anyone in your family having sleep apnea (OSA)
Stopping breathing when sleeping/awakening with a gasp

Do you notice any of the following about your child?

	YES	No	Not Sure
Snoring/noisy breathing while sleeping
Grinding his or her teeth
Wetting the bed
Having difficulty in school/learning
Being treated for ADD/ADHD
Breathing primarily through their mouth
Having frequent nightmares/night terrors
Having frequent ear aches

I certify that I, and/or my dependent(s), have insurance coverage with with withName of Insurance Company(ies) and assign directly to Lizette Barzaga, DDS all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

I have read BL Dental Miami's HIPAA Acknowledgement and Financial Policy Forms, and agree to both.

Signature of Patient, Parent, Guardian or Personal Representative

Sleep Apnea Questionnaire

Epworth Sleepiness Scale (ESS)

Check all of the following that you have been diagnosed or treated for:

AUTHORIZATION