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  • Dr. Darrell Morden
    1107-37th St. SW Calgary, AB T3C 1S5
    (403) 242 5777

  • SLEEP QUESTIONNAIRE FOR DIAGNOSED SLEEP APNEA PATIENTS

  • Dr. Darrell Morden DDS Diplomate, American Board of Dental Sleep Medicine
  • PLEASE SET ASIDE TIME TO COMPLETE THIS FORM ACCURATELY
  • Date :
     - -
    2 digit day, 2 digit month, 4 digit year
  • How did you hear about Our Clinic?

  • PERSONAL INFORMATION

  • Date of Birth:
     - -
    2 digit day, 2 digit month, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • As applicable
  • CHIEF COMPLAINTS / REASONS FOR CONSULTATION
  • Page 1

  • SLEEP CENTRE EVALUATION(S)

  • Previous Sleep Clinic or Sleep Physician evaluation(s)?
  • Overnight study:
  • Diagnosis List
  • Previous Insomnia / Cognitive-behavioral interventions?

  • THERAPY ATTEMPTS

  • CPAP (CONTINUOUS POSITIVE AIRWAY PRESSURE) HISTORY

  • I am or
  • If in use, average hours/night worn:
  • I sleep better using CPAP?
  • I feel more refreshed the next morning having used CPAP
  • (See next for CPAP problems list)
  • Page 2

  • CPAP INTOLERANCE / PROBLEMS

  • CPAP INTOLERANCE / PROBLEMS

  • SLEEP HISTORY / NORMAL HABITS

  • Difficulty returning to sleep?
  • Do you dream
  • Sleep aid / medication?
  • Napping
  • Awakenings/Interrupted sleep caused by:
  • Awakenings/Interrupted sleep caused by:
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  • DAYTIME SLEEPINESS PROBLEMS (EPWORTH SLEEPINESS SCALE)

  • How likely are you to doze off or fall asleep in the following situations?
    (Even if not a recent thing, think on how they would have affected you in these specific examples)
  • Sitting and reading
  • Watching TV / Movie 0
  • Sitting inactive (Meeting, Theatre)
  • As a passenger a car for an hour
  • Lying down to rest in the afternoon
  • Sitting and talking to someone
  • Sitting quiet after lunch, no alcohol
  • In a car, stopped in traffic

  • SOCIAL HISTORY

  • Alcoholic beverage
  • Caffeine beverage
  • Nicotine/replacement
  • CBD/THC/Marijuana
  • Evening consumption
  • SHIFT WORK?
  • SLEEP DEPRIVATION

  • CLINIC USE

  • Height

  • Neck Circumference

  • Weight

  • Mallampati Score
  • PAL VAULT
  • Tongue
  • Crowding
  • TMJ joint
  • NASAL breathing
  • PERIO
  • Date
     - -
    2 digit day, 2 digit month, 4 digit year
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  • Dr. Darrell Morden
    1107-37th St. SW Calgary, AB T3C 1S5
    (403) 242 5777

  • Consent for Disclosure of Personal Information

  • info@westcalgarydentalgroup.com

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  • To From

  • I acknowledge that I have been made aware of the reasons for the disclosure of the above information, and the risks and benefits associated with consenting or not consenting to its release. I understand that I make revoke my consent at any time, by providing a signed, written statement to my West Calgary Dental Group.
  • Format: (000) 000-0000.
  • Date:
     - -
    2 digit day, 2 digit month, 4 digit year
  • Page 6
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