JC Goodwin DMD, DACSDD, DABDSM

3192 N Windsong Dr. Prescott Valley, AZ 86314

928-778-4555

Sleep Apnea Questionnaire and Affidavit of CPAP Intolerance

Patient Name
Phone
Email
Have you ever had past TMJ problems?
Do you have TMJ pain/problems now?
Have you been diagnosed with sleep apnea?
If so, approximately when was the sleep study performed? Date:
What is the name and location of the sleep center you used?
Were you prescribed a CPAP machine?
If so, are you using it?
Have you tried other apnea therapies (surgery, wt. loss, etc)
list:

If you cannot tolerate CPAP or choose not to use it, please indicate the reason(s) why:

Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Using the following scale, circle the most appropriate number for each situation.

0=Would NEVER doze, 1=SLIGHT chance of dozing, 2=MODERATE chance of dozing, 3=HIGH chance of dozing

Sitting and reading 0 1 2 3
Watching TV 0 1 2 3
Sitting, inactive, in a public place (theater, meeting, etc) 0 1 2 3
As a passenger in a car for an hour without a break 0 1 2 3
Lying down to rest in the afternoon when circumstances permit 0 1 2 3
Sitting and talking to someone 0 1 2 3
Sitting quietly after lunch without alcohol 0 1 2 3
In a car, while stopped for a few minutes in traffic 0 1 2 3
Total

I believe the information provided above to be complete and accurate. I authorize the release of a full report of examination findings, diagnosis, treatment programs, etc., to any referring or treating dentist or physician, and I authorize the release of any medical information to insurance companies for legal documentation necessary to process claims.

Signature

Use your mouse cursor or the tip of your finger to sign below

Date