SLEEP HISTORY QUESTIONNAIRE
Please print, fill out, and either fax, mail or bring this form with you to our office.

DATE_____________

PATIENT'S NAME____________________________________________

DENTAL HISTORY

PLEASE CIRCLE YES OR NO. IF YES, PLEASE GIVE DETAILS.

ARE YOU PRESENTLY IN ANY DENTAL PAIN? _____________________________ YES NO

HAVE YOU EVER EXPERIENCED ANY UNFAVORABLE REACTION TO
DENTISTRY? WHAT? _______________________________________________ YES NO

HAVE YOU LOST ANY TEETH? FROM WHAT CAUSE? ________________________ YES NO

DO YOU HAVE ANY GROWTHS OR SWELLINGS IN YOUR MOUTH? HOW
LONG HAVE THEY EXISTED? __________________________________________ YES NO

DO YOU HAVE ANY DIFFICULTY IN SWALLOWING? ________________________ YES NO

DO YOUR GUMS BLEED WHEN BRUSHING YOUR MOUTH? _____________________ YES NO

DO YOU AVOID BRUSHING ANY PART OF YOUR MOUTH? WHY? _______________ YES NO

HAVE YOU EVER BEEN TOLD YOU HAVE PYORRHEA? WHEN? _________________ YES NO

IS ANY PART OF YOUR MOUTH SENSITIVE TO TEMPERATURE, PRESSURE
OF FOOD OR DRINK? WHAT? ________________________________________ YES NO

DO YOU HAVE A BURNING SENSATION OF YOUR MOUTH? ___________________ YES NO

DOES FOOD CATCH BETWEEN YOUR TEETH? _______________________________ YES NO

DO YOU HAVE ANY PAIN OR SORENESS AROUND YOUR EYES OR EARS OR
OTHER PARTS OF YOUR FACE? WHEN? _________________________________ YES NO

ARE YOU AWARE OF STIFF NECK MUSCLES? HOW OFTEN? ___________________ YES NO

DO YOU EVER AWAKEN WITH AN AWARENESS OF YOUR TEETH OR JAWS? HOW OFTEN? YES NO

ARE YOU AWARE OF CLENCHING YOUR TEETH DURING YOUR DAYTIME

HOURS? HOW OFTEN? ___________________________________________________ YES NO

HAVE YOU EVER BEEN TOLD YOU GRIND YOUR TEETH DURING SLEEP? HOW OFTEN? YES NO

ARE YOU AWARE OF YOUR JAW CLICKING OR POPPING WHILE EATING

OR YAWNING? HOW OFTEN? ____________________________________________ YES NO

DO YOU HAVE DIFFICULTY IN OPENING YOUR MOUTH WIDELY? _____________ YES NO

DO YOU HAVE "TENSION" HEADACHES? HOW OFTEN? _______________________ YES NO

DO YOU HAVE AN UNPLEASANT TASTE OR ODOR IN YOUR MOUTH? ___________ YES NO

MEDICAL HISTORY

FAMILY PHYSICIAN __________________________SPECIALTY____________________

ADDRESS

_________________________________________________________________________
STREET CITY ZIP TELEPHONE

ADDITIONAL PHYSICIAN _______________________SPECIALTY ___________________

ADDRESS

_________________________________________________________________________
STREET CITY ZIP TELEPHONE

HEIGHT ____WEIGHT ____AGE __ DATE OF LAST COMPLETE MEDICAL EXAM ________

PLEASE CIRCLE YES OR NO. IF YES, PLEASE FILL IN DETAILS.

DO YOU HAVE A CURRENT MEDICAL PROBLEM? WHAT? _____________________ YES NO

DO YOU HAVE HEART TROUBLE? WHAT KIND? _____________________________ YES NO

HAVE YOU HAD RHEUMATIC FEVER? WHEN? ______________________________ YES NO

DO YOU HAVE HIGH OR LOW BLOOD PRESSURE? IS IT CONTROLLED? ________ YES NO

HAVE YOU HAD PAINS IN THE CHEST OR SHORTNESS OF BREATH? __________ YES NO

DO YOUR ANKLES EVER SWELL? _______________________________________ YES NO

HAS YOUR PHYSICIAN EVER TOLD YOU THAT YOU ARE ANEMIC? ____________ YES NO

HAVE YOU EVER HAD A STROKE? WHEN? ________________________________ YES NO

DO YOU HAVE DIABETES? HOW IS IT CONTROLLED? ______________________ YES NO

ARE YOU SUBJECT TO FAINTING OR DIZZINESS? WHEN? __________________ YES NO

DO YOU HAVE HEADACHES? HOW OFTEN? ________________________________ YES NO

DO YOU HAVE PROBLEMS WITH INSOMNIA? HOW OFTEN? ___________________ YES NO

DO YOU HAVE ANY NERVOUS DISORDER? HOW IS IT CONTROLLED? __________ YES NO

DO YOU TAKE TRANQUILIZERS OR SEDATIVES? HOW OFTEN? _______________ YES NO

DC YOU TAKE ASPIRIN? HOW OFTEN? __________________________________ YES NO

ARE YOU ALLERGIC TO ANY MEDICATION? WHAT? ________________________ YES NO

HAVE YOU BEEN ADVISED NOT TO TAKE ANY MEDICATION? ________________ YES NO

DO YOU HAVE ASTHMA OR HAY FEVER? HOW IS IT CONTROLLED? ___________ YES NO

HAVE YOU EVER HAD TUBERCULOSIS? WHEN? ____________________________ YES NO

HAVE YOU EVER BEEN TESTED FOR HEPATITIS? WHEN? ___________________ YES NO

HAVE YOU EVER HAD INFECTIOUS HEPATITIS? WHEN? ____________________ YES NO

HAVE YOU EVER BEEN TESTED FOR AIDS? WHEN? ________________________ YES NO

DO YOU HAVE ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS)? __________ YES NO

DO YOU HAVE ARTHRITIS? HOW IS IT CONTROLLED? _____________________ YES NO

HAVE YOU EVER HAD A TUMOR OR CANCER? HOW WAS IT TREATED? _________ YES NO

HAVE YOU HAD ANY MAJOR OPERATIONS? WHAT KIND? ____________________ YES NO

HAVE YOU EVER BEEN INVOLVED IN A SERIOUS ACCIDENT? _______________ YES NO

ARE YOU TAKING ANY MEDICATION? PLEASE LIST:

HAVE YOU GAINED OR LOST WEIGHT WITHIN THE LAST YEAR? HOW MUCH? ___ YES NO

DO YOU BECOME FATIGUED EASILY? AT WHAT TIME OF DAY? ______________ YES NO

DO YOU ROUTINELY EAT BREAKFAST? WHAT? ____________________________ YES NO

DC YOU TAKE MORE THAN ONE ALCOHOLIC DRINK PER DAY? HOW MANY? _____ YES NO

DO YOU USE TOBACCO? HOW MUCH? ____________________________________ YES NO

IS YOUR DIET MEDICALLY SUPERVISED? FOR WHAT PURPOSE? _____________ YES NO

DO YOU HAVE AN IRREGULAR OR ABNORMAL SLEEP-WAKE SCHEDULE? ________ YES NO

DO YOU HAVE A PROBLEM FALLING ASLEEP AT NIGHT? ___________________ YES NO

DC YOU HAVE A PROBLEM BECAUSE OF WAKING UP DURING THE NIGHT? _____ YES NO

DO YOU HAVE A PROBLEM BECAUSE OF AWAKENING TOO EARLY AND NOT
BEING ABLE TO GET BACK TO SLEEP? _________________________________ YES NO

DO YOU HAVE DIFFICULTY GETTING OUT OF BED AND FUNCTIONING
EI'FECTIVELY FIRST THING IN THE MORNING? _________________________ YES NO

DO YOU HAVE A PROBLEM BECAUSE OF SLEEPINESS OR DROWSINESS IN
THE DAYTIME OR EARLY EVENING? ____________________________________ YES NO

DO YOU HAVE A PROBLEM BECAUSE OF DISCOMFORT OR PAIN
DISTURBING YOUR SLEEP? YES NO

DO YOU HAVE ABNORMAL MOVEMENTS OR EXCESSIVE RESTLESSNESS
DURING YOUR SLEEP? _______________________________________________ YES NO

DO YOU SNORE LOUDLY OR HAVE ANY ABNORMALITY OF YOUR BREATHING DURING SLEEP? YES NO

DC) YOU USE MEDICATION TO HELP YOUR NIGHTTIME SLEEP OR DAYTIME ALERTNESS? YES NO

DOES YOUR BED PARTNER OR ANYBODY ELSE WHO HAS OBSERVED YOUR
SLEEP FEEL THAT YOUR SLEEP IS ABNORMAL? ___________________________ YES NO

DC) YOU HAVE ANY MEDICAL PROBLEMS NOT COVERED BY THIS QUESTIONNAIRE THAT WE NEED TO BE AWARE OF? _______________________________________ YES NO

FOR WOMEN

ARE YOU PREGNANT? EXPECTED DELIVERY DATE? _______________________ YES NO

DO YOU HAVE ANY HISTORY OF PREVIOUS MISCARRIAGES? ________________ YES NO

HAVE YOU REACHED MENOPAUSE? IF SO, ARE YOU TAKING SUPPORTIVE MEDICATION? YES NO

I HEREBY STATE THAT I HAVE TRUTHFULLY TO THE BEST OF MY ABILITY ANSWERED ALL THE ABOVE QUESTIONS.

SIGNATURE _______________________________ DATE _____________________________

Revised 8/10/93