SLD Sleep and Bite Questionnaire
Patient Name :
*
First Name
Middle Name
Last Name
Has anyone ever told you that you snore?
*
Yes
No
Has anyone in your family been diagnosed with sleep apnea?
*
Yes
No
Do you have high blood pressure?
*
Yes
No
Have you been diagnosed with sleep apnea?
*
Yes
No
If yes, how are you currently treating it?
Have you noticed a change in how your teeth come together?
*
Yes
No
Do you have pain or noise in your jaw joint?
*
Yes
No
Do you grind or clench your teeth at day or night?
*
Yes
No
Do your jaw muscles feel tired after eating?
*
Yes
No
Do you get headaches or migraines?
*
Yes
No
Have you ever worn a bite splint or night guard?
*
Yes
No
Date :
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Print Form
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