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Health History Form

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Today's Date

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

PERSONAL INFORMATION

First Name

Last Name

MI

Birth Date

Age

Sex

Insurance ID #

Mailing Address

City

State

Zip

Best Phone # To Reach You

Alternative Phone #

Cell Phone #

Cell Phone Provider

Prefered Method of Contact

Phone

Text

Email

Marital Status

Height(In.)

Weight (#)

CHIEF COMPLAINT: Briefly describe your problem with your sleep as you see it:

Have you had a significant weight gain or loss in the past few years

Employer

Occupation

MEDICAL INFORMATION

Last Set of Dental X-Rays Date

Dentist Name

Emergency Contact

Relationship

Contact Phone #

Alternative Phone #

Referring Sleep Physician

Primary Care Physician

Dentist of Record

Have you had any of the following?

Constitutional

Unexplained appetite changes

Yes

No

Unusual weakness

Yes

No

Recent trauma

Yes

No

Recent infection

Yes

No

Tire easily

Yes

No

Recent marked weight changes

Gain

Loss

Sensitivity to heat or cold

Yes

No

Night sweats

Yes

No

Head

Chronic facial pain

Yes

No

Chronic headache pain

Yes

No

Day-time

Yes

No

Night-time

Yes

No

Neck

Neck pain

Yes

No

Swelling

Yes

No

Stiffness

Yes

No

Eyes

Double vision

Yes

No

Blurred vision

Yes

No

Ears

Stuffiness in ears

Yes

No

Ringing in ears

Yes

No

Discharge

Yes

No

Ear pain

Yes

No

Nose

Change of smell (not associated with illness)

Yes

No

Nasal obstruction (not associated with illness)

Yes

No

Excessive sneezing

Yes

No

Nasal allergies

Yes

No

Frequent sinus infections

Yes

No

Throat

Chronic soreness

Yes

No

Chronic hoarseness

Yes

No

Difficulty swallowing

Yes

No

Cardiovascular

High Cholesterol

Yes

No

Atrial Fibrillation

Yes

No

Stroke

Yes

No

Heart murmur

Yes

No

Rheumatic fever

Yes

No

Palpitations

Yes

No

Chest pain

Yes

No

High blood pressure

Yes

No

Chest tightness

Yes

No

Swelling of ankles

Yes

No

Heart attack

Yes

No

Pulmonary

Persistent cough

Yes

No

Labored breathing

Yes

No

Hard to breath laying down

Yes

No

Yellow or green sputum

Yes

No

Wheezing

Yes

No

Pneumonia

Yes

No

Tuberculosis

Yes

No

COPD

Yes

No

Asthma

Yes

No

Gastrointestinal

Unexplained nausea

Yes

No

Chronic Diarrhea

Yes

No

Chronic constipation

Yes

No

Heartburn

Yes

No

GERD (reflux)

Yes

No

Hepatitis (liver disease)

Yes

No

Genitourinary

Kidney disease

Yes

No

Difficulty urinating

Yes

No

Loss of libido

Yes

No

Musculoskeletal

Pain in joints

Yes

No

Joint injections

Yes

No

Joint or muscle pain that alters sleep position

Yes

No

Restless leg syndrome

Yes

No

Fibromyalgia

Yes

No

Neurological

Loss of memory

Yes

No

Disorientation

Yes

No

Fainting

Yes

No

Dizziness

Yes

No

Vertigo

Yes

No

Clumsiness

Yes

No

Muscle paralysis

Yes

No

Muscle weakness

Yes

No

Depression

Yes

No

ADHD

Yes

No

Anxiety

Yes

No

Endocrine

Thyroid condition

Yes

No

Adrenal condition

Yes

No

Cortisone treatments

Yes

No

Bleeding

Yes

No

Diabetes I

Yes

No

Diabetes II

Yes

No

Women

Pre-menopausal

Yes

No

Peri-menopausal

Yes

No

Post-menopausal

Yes

No

Could you be pregnant?

Yes

No

Hot flashes

Yes

No

Are you nursing?

Yes

No

Have you or any family member have history of the following?

Snoring

Yes

No

If yes, please specifiy relationship.

Obstructive Sleep Apnea

Yes

No

If yes, please specifiy relationship.

Heart Disease

Yes

No

If yes, please specifiy relationship.

Depression

Yes

No

If yes, please specifiy relationship.

Obesity

Yes

No

If yes, please specifiy relationship.

Cancer

Yes

No

If yes, please specifiy relationship.

Please list any surgeries you have had with date:

Are you current with your childhood immunizations?

Yes

No

If not, which ones are not?

Please list all medications - include name, dose (mg, drops, etc), frequency (daily, at bed time, etc), and reason for taking (blood pressure, diabete, etc)

Emergency Information

Have you been evaluated at a sleep disorders center before?

Yes

No

If yes, When (Date)

If yes, Where

What were you told the problem was?

What treatment were you given?

Why are you being evaluated again?

Have you had any surgeries to treat your sleep symptoms?

Yes

No

Do you work varying shifts or nighttime shifts?

Yes

No

Have you been treated with CPAP?

Yes

No

If you are not using CPAP, explain why

Social History

Do you smoke tobacco?

Yes

No

If yes, how much per day?

How long have you smoked?

If you smoke tobacco, do you smoke when you wake up during the night?

Yes

No

If you smoke, have you noticed that nicotine alters or interferes with your sleep?

Yes

No

Do you usually drink coffee, tea, chocolate, cola or other caffeinated beverages with in 3 hours of your bedtime?

Yes

No

How many of the following caffeinated drinks do you have per day?

Coffee/Tea

Cola

Chocolate

Other

Do you drink alcoholic beverages?

Yes

No

Assuming the following drinks are equivalent-12oz. beer/5 oz. Wine/3 oz vodka etc. then:

How many drinks do you have in a usual weekday?

On a weekend or holiday?

Do you drink alcohol within two hours of bedtime?

Yes

No

Do alcoholic beverages alter or interfere with you sleep?

Yes

No

Have you ever used alcohol in order to get to sleep?

Yes

No

Have you ever sought treatment/counseling for an alcohol problem?

Yes

No

If yes, Date

TMJ History

Have you experienced any of the following?

Night time grinding

Yes

No

Night time clenching

Yes

No

Daytime clenching

Yes

No

Use of occlusal guard to prevent grinding and/or clenching

Yes

No

History of joint locking

Yes

No

Clicking in right joint

Yes

No

Clicking in left joint

Yes

No

Headaches caused by TMD

Yes

No

Facial muscle pain

Yes

No

Drug and Other Allergies

Are you allergic to any drugs?

Yes

No

If yes, which?

What reaction happened when you took it?

Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following circumstances, in contrast to feeling just tired? This refers to your usual way of life in recent times. Using the scale below, select the most appropriate number for each situation.

Scale: 0 - Would Never Fall Asleep 1 - Slight Chance of Dozing 2 - Moderate Chance of Dozing 3 - High Chance of Dozing

Sitting and Reading

Watching Television

Sitting inactive in a public place (theater)

A passenger in a car for an hour without a break

Lying down to rest in the afternoon when possible

Sitting and talking to someone

Sitting quietly after a lunch without alcohol

In a car while stopped for a few minutes in traffic

Total

Overall quality of sleep

Poor

Average

Good

Patient Signature

Date

Update Form

Have you been ill at all during the last two weeks?

Yes

No

Any respiratory symptoms, viral symptoms or fever or have you travelled to a foreign country during the last two weeks?

Yes

No

Did you travel out of the country in the last two weeks?

Yes

No

Were you exposed to anybody who tested positive for Corona Virus in the last 2 weeks?

Yes

No

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my doctor and their staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of their staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Patient Name

Date of Birth

Signature

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.