Sleep Apnea History | DogwoodFamilyDental

Sleep Apnea History and Workup

Medical Insurance

Subscriber Name

Subscriber Date of Birth

Subscriber ID/SSN

Group Number (if applicable)

Claims Mailing Address

Medical History - have you been diagnosed or are taking medication for any condition?

Medication - Please list any medications prescribed by your physician.

Do you have any jaw or TMJ pain?

Yes

How likely are you to fall asleep/doze with the following: Sleeping and Reading

Watching TV

Sitting in a public place? (i.e. theater or meeting)

Sitting in the car as a passenger without a break

Lying down to rest

Sitting and talking to someone?

Sitting quietly after lunch?

In a car stopped for a few minutes in traffic?

Have you tried a CPAP/BiPAP machine?

Yes

Have you had any surgeries or tried any other therapies for sleep apnea?

Yes

Date of Last Sleep Study - please upload a copy below if possible

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