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Murray Questionnaire

This questionnaire is designed to help us understand your chief complaints of sleep apnea, as well as get to know your sleep apnea history. Please take time to fill this out to your best knowledge.

Sleep Apnea Questionnaire

"*" indicates required fields

Step 1 of 3

33%

Patient Name*

First Last

Height*

Weight*

Email*

Date of Birth*

Month

Day

Year

Home Phone

Cell Phone*

Preferred Sound Sleep Medical Location*

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Referred by:

Primary Care Physician

Primary Care Physician Phone Number

Sleep Physician

Sleep Physician Phone Number

Dentist

Dentist Phone Number

Insurance Information

Primary Insurance Company*

Primary Policy Holder Name*

Primary Policy Holder Date of Birth*

MM slash DD slash YYYY

Primary Group #*

Primary Policy Holder ID#*

Secondary Insurance Company

Secondary Policy Holder Name

Secondary Policy Holder Date of Birth

MM slash DD slash YYYY

Secondary Group #

Secondary Policy Holder ID#

This field is hidden when viewing the form

Secondary Insurance Company

This field is hidden when viewing the form

Secondary Policy Holder Name

This field is hidden when viewing the form

Secondary Policy Holder Date of Birth

MM slash DD slash YYYY

This field is hidden when viewing the form

Secondary Policy Holder ID#

This field is hidden when viewing the form

Secondary Group #

Emergency Contact Information

Emergency Contact Name*

First Last

Emergency Contact Phone*

Emergency Contact Relationship*

Have you ever had a sleep test?*

Yes

No

If yes, when was your last sleep test? Who provided the test?*

Are you currently taking any medications?*

Yes

No

If yes, please list medication and dosage:*

Communication Preference:

Your Privacy is important to us. Please let us know how we can contact you.

May we contact you via email for treatment follow up?*

Yes

No

May we leave message on your answering machine or phone?*

Yes

No

Is there anyone, other than yourself, with whom we may discuss your appointment/treatments?*

Yes

No

Please list name & phone number:*

Dental Health Questionnaire

Dentist Name

First Last

Dentist Phone

Patient Dental History:

Date of Last Dental Cleaning:

MM slash DD slash YYYY

Do you get your teeth cleaned at least once a year?*

Yes

No

Date of Last Dental Examination:

MM slash DD slash YYYY

Do you have dental work that needs to be done?*

Yes

No

If yes, what dental work is needed?*

Have you had orthodontic treatment (braces, Invisalign, etc.)?*

Yes

No

If yes, at what age?

Patient Questionnaire (please check yes or no):

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Do you have less than 10 teeth on your top jaw?*

Yes

No

This field is hidden when viewing the form

If yes, how many do you have?

Are you missing more than four teeth on either your upper or lower jaw?

Yes

No

This field is hidden when viewing the form

Do you have less than 10 teeth on your lower jaw?*

Yes

No

This field is hidden when viewing the form

If yes, how many do you have?

Have you been told you have gum disease? (periodontal disease)*

Yes

No

Do your gums bleed when you brush or floss?*

Yes

No

Are your gums infected?*

Yes

No

Do your teeth hurt?*

Yes

No

Do you have any crowns?*

Yes

No

Do you have any fillings?*

Yes

No

Do you have any broken teeth?*

Yes

No

Do you have dentures or removable partials?

Yes

No

Do you have any loose teeth?

Yes

No

Have you been told that you have TMJ (TMD) or jaw problems?*

Yes

No

Does your jaw ever hurt?*

Yes

No

If yes, how often?

This field is hidden when viewing the form

If yes, how often?

Does your jaw pop or make noise?*

Yes

No

Does your jaw hurt when you chew?*

Yes

No

This field is hidden when viewing the form

If yes, how often?

Does your jaw ever lock open?*

Yes

No

If yes, how often?

Is it hard or painful to open your mouth wide?*

Yes

No

If yes, how often?

Do you get frequent headaches?*

Yes

No

This field is hidden when viewing the form

If yes, how often?

This field is hidden when viewing the form

Do you have dentures or removable partials?*

Yes

No

This field is hidden when viewing the form

Do you have any loose teeth?*

Yes

No

Sleep Health Questionnaire

Please Check Any Symptoms Below That Apply to You*

Anxiety

Facial Surgery or Trauma

Teeth Grinding

Morning Jaw Pain

Morning Headaches

Diabetes

Depression

Oral or Nasal Surgery

Ehlers-Danlos Syndrome (elastic skin)

Hay Fever/Sinus Infections

Fatigue

Memory Loss

Claustrophobia

Stroke

History of Allergies

Excessive Daytime Sleepiness

Impaired Cognition

Chronic Bloody Nose

Frequent/Heavy Snoring

Nighttime Choking Spells

Air/Bleeding in Chest

High Blood Pressure

Collapsed Lung

Low Blood Pressure

Heart Disease

Dry Mouth

Emphysema (Shortness of Breath)

Told I Stop Breathing During Sleep

Respiratory Failure

Lack of Concentration

Other (Please Specify):

If you have received treatment for any checked above

Physician Name

First Last

Treatment Date

MM slash DD slash YYYY

EPWORTH SCALE ASSESSMENT

Please read through the situations below and answer how likely you are to doze off. Use the scale below to choose the most appropriate number for each situation.

0 = No Chance of Dozing< /td>

1 = Slight Chance of Dozing

2 = Moderate Chance of Dozing

3 = High Chance of Dozing

Dozing off while sitting and reading?

Please enter a number from 0 to 3.

Dozing off while watching TV?

Please enter a number from 0 to 3.

Dozing off while sitting in a public place? (meeting, theatre, etc.)

Please enter a number from 0 to 3.

Dozing off while riding as a passenger in a car?

Please enter a number from 0 to 3.

Dozing off while sitting and talking to someone?

Please enter a number from 0 to 3.

Dozing off while sitting quietly after lunch?

Please enter a number from 0 to 3.

Dozing off while driving a car and stopped for a few minutes in traffic?

Please enter a number from 0 to 3.

Dozing off when lying down in the afternoon, when circumstances permit?

Please enter a number from 0 to 3.

Your Total

Release of Information:

I authorize Sound Sleep Medical LLC to release any medical information requested by insurance companies, and to representatives of local, state, and federal agencies, if applicable. I also authorize Sound Sleep Medical LLC to request any medical records needed regarding my sleep apnea history.

Patient Signature:*

Please enter your full name. This e-signature will be considered equal to a physical (pen & paper) signature.

Date

MM slash DD slash YYYY

Patient Name

First Last

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Home
About Us
Sleep Solutions
Our Locations
- Nevada
  - Henderson
  - Las Vegas
- Utah
Insurance
Blog
Schedule Now

Simply answer the following 5 questions Yes or No to see if you qualify.
If you have any questions or concerns please call: 801-762-6888.

Step 1 of 5

20%

I wake up gasping for air during the night?(Required)

I have been told that I snore?(Required)

I am over the age of 30?(Required)

I feel tired during the day?(Required)

Congratulations!!!

You qualify for a free sleep assessment to try this revolutionary new sleep apnea device. Please provide us your contact info, so we can schedule your free assessment.

Name(Required)

First Last

Phone(Required)

Email

Zip Code(Required)

Please enter your 5 digit zip code

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