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  • NEW PATIENT INTAKE/INFORMATION

  • DATE OF BIRTH:*
     / /
    2 digit day, 2 digit month, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do you have Dental Coverage/Insurance?
  • Please check ANY of the conditions listed below which are affecting you:
  • Conditions*
  • DATE
     - -
    2 digit day, 2 digit month, 4 digit year

  • Epworth Sleepiness Scale

    FOR PATIENT
  • This section is for the Patient to complete. Are you filling these questions out as, or with the Patient in mind?*
  • Date:*
     / /
    2 digit day, 2 digit month, 4 digit year

  • The Epworth Sleepiness Scale is a valuable tool used to screen for Sleep Apnea. It uses your self reported level of daytime sleepiness as a predictor for the likelihood of a serious sleep issue.

    Please answer the questions below by scoring each with "0" to "3"

    0. Would never doze
    1. Slight chance of dozing
    2. Moderate chance of dozing
    3. High chance of dozing

  • Please answer the questions for YOURSELF (the patient) below by scoring each with "0" to "3" using the above scoring.*
    Rows
  • Have you ever had a Sleep Study Test?
  • Date
     - -
    2 digit day, 2 digit month, 4 digit year
  • Have you ever been diagnosed with Sleep Apnea?
  • Date:
     - -
    2 digit day, 2 digit month, 4 digit year
  • Have you been prescribed a CPAP machine?
  • Date:
     - -
    2 digit day, 2 digit month, 4 digit year
  • If YES, do you wear it regularly?
  • Date:
     - -
    2 digit day, 2 digit month, 4 digit year
  • Do you feel refreshed upon wakening?
  • Date:
     - -
    2 digit day, 2 digit month, 4 digit year
  • Please Note: If you live with a spouse/partner please have them complete this form separately - See page 3.

  • Epworth Sleepiness Scale

    FOR SPOUSE/PARTNER OF PATIENT REGARDING THE PATIENT'S SLEEP HABITS
  • Only if applicable, please have your spouse, partner, or significant other answer the below questions if they have seen or heard your sleeping/sleeping habits. Are you a spouse/partner/significant other/etc?
  • Date:
     / /
    2 digit day, 2 digit month, 4 digit year

  • The Epworth Sleepiness Scale is a valuable tool used to screen for Sleep Apnea. It uses your self reported level of daytime sleepiness as a predictor for the likelihood of a serious sleep issue.

    Please answer the questions below by scoring each with "0" to "3"

    0. Would never doze
    1. Slight chance of dozing
    2. Moderate chance of dozing
    3. High chance of dozing

  • Please answer the questions for YOURSELF (the patient) below by scoring each with "0" to "3" using the above scoring.
    Rows
  • Have you ever had a Sleep Study Test?
  • Date
     - -
    2 digit day, 2 digit month, 4 digit year
  • Have you ever been diagnosed with Sleep Apnea?
  • Date:
     - -
    2 digit day, 2 digit month, 4 digit year
  • Have you been prescribed a CPAP machine?
  • Date:
     - -
    2 digit day, 2 digit month, 4 digit year
  • If YES, do you wear it regularly?
  • Date:
     - -
    2 digit day, 2 digit month, 4 digit year
  • Do you feel refreshed upon wakening?
  • Date:
     - -
    2 digit day, 2 digit month, 4 digit year

  • Now Let's Talk About You

  • Please fill out this page and bring it with you for your first appointment. This information will help us quickly understand your needs, and in the process provide you with excellent, patient-focused service.
  • Our patients have found that filling out this form helps them to think about what they want out of their dental visits and how we can help in the best way possible. So, grab a pen and let us know more about you!
  • I'm having pain or discomfort?
  • PLEASE LIST ANY DOCTORS YOU ARE SEEING (OR HAVE SEEN), FOR ANY OF THE CONDITIONS YOU'VE LISTED ON PAGE 1.
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  • I,   *   *   , hearby authorize the release of communications regarding my treatment with Dr. David E. Rawson @ TMJ & Sleep Therapy Office, including a full report of examination findings, diagnosis, treatment plan, and progress reports to the healthcare providers listed above.

  • DATE
     - -
    2 digit month, 2 digit day, 4 digit year
  • We're looking forward to treating you!
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