Snore Centre New Patient Form

Medical History

Name*

First Last

Date of Birth:*

Address*

Street Address City Province Postal Code Country

Phone*

Email*

Occupation*

Height (m)*

Weight (kg)*

Gender*

Male
Female

Healthcare Number*

Family Doctor

Address of Family Doctor's Office

Doctor's Phone Number

Last Doctor Visit:

Medical Specialist

Address of Medical Specialist 's Office

Medical Specialist's Phone Number

Do you believe you are in good health?*

Describe any notable changes in your health in the past 2 years*

Do you have any allergies?*

Yes
No

Please list*

Are you currently taking any medications?*

Yes
No

Please provide a list of any medications you are currently taking either on your own (over the counter) or prescribed by your doctor.*

When was the last time you visited your dentist?*

How many nights a week do you consume alcoholic beverages?*

On average, how many beverage per night?*

Do you smoke?

yes
no

How many years have you been smoking?*

How many cigarettes do you consume in a day?*

In each of the following categories please check off the items to describe your current medical profile and history.

Gastrointestinal (Stomach & Intestines)

Ulcers
Persistent diarrhea
Gag reflex
GERD

Gastrointestinal (Stomach & Intestines)

Ulcers
Persistent diarrhea
Gag reflex
GERD

(Stomach & Intestines)

Cardiovascular (Heart & Circulation)

Heart disease
Rheumatic fever
Heart attack
Angina
Blood pressure
Anemia
Swollen ankles
Stroke

Heart disease type*

When did you have your last heart attack?

What's your blood pressure?*

High
Low

Neural (Brain & Nerves)*

Severe Headaches
Migraine headaches
Epilepsy or seizures
Psychiatric treatment
Anxiety or Panic Attacks
Depression
Bipolar disorder
Schizophrenia
Other

What other neural issue do you have?*

Respiratory (Breathing)

Hay fever
Asthma
Chronic cough
Shortness of breath
Emphysema

Endocrine (Glands & hormones)

Diabetes
Thyroid disease

Other

Tumor
Cancer
Night sweats

Do you have any infection disease that we should be informed (HIV, Hepatitis, etc.)

Please describe anything else we should know that will assist us to treat you, or make your visit to our office more comfortable

The Snore Centre Personal Information Consent Form

This field is hidden when viewing the form

We are committed to protecting the privacy of our client’s personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we will collect, use and disclose. In addition to the circumstances described in this form, we also collect, use and disclose personal information when permitted or required by law. 
We Collect information from our clients such as names, home addresses, work addresses, home telephone numbers, work telephone numbers, and email addresses etc. Contact information is collected and used for the following purpose:
<ul>
	<li>To open and update client files.</li>
	<li>To invoice clients for dental services, to process credit card payments, or to collect unpaid accounts.</li>
	<li>To send reminders to patients concerning the need for further examination or treatment.</li>
	<li>To send patients informational material about our practice.</li>
</ul>
Financial information may be collected in order to make arrangements for the payment of services.
We collect information from our clients about their health history, their family health history, physical condition, and dental treatments (collectively referred to as “medical information”). Client’s medical information is collected and used for the purpose of diagnosing dental 
conditions and providing care Clients’ medical information is disclosed to other healthcare professionals:
<ul>
	<li>Where we are seeking a second opinion.</li>
	<li>Where the client, has been referred by us to a healthcare professional for treatment.</li>
	<li>Where those professionals have asked us, to provide a second opinion.</li>
</ul>
If we are ever considering selling all or part of our practice, qualified potential purchasers may be granted access as part of the due diligence process to client information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure 
that the prospective purchaser safeguards all personal information.
Dentists are regulated by the Alberta Dental Association which may inspect our records and interview our staff as part of it regulatory activities in the public interest.
I Consent to the collection, use and disclosure of my personal information as stated above.

The Snore Centre Personal Information Consent Form
We are committed to protecting the privacy of our client’s personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we will collect, use and disclose. In addition to the circumstances described in this form, we also collect, use and disclose personal information when permitted or required by law.
We Collect information from our clients such as names, home addresses, work addresses, home telephone numbers, work telephone numbers, and email addresses etc. Contact information is collected and used for the following purpose:

To open and update client files.
To invoice clients for dental services, to process credit card payments, or to collect unpaid accounts.
To send reminders to patients concerning the need for further examination or treatment.
To send patients informational material about our practice.

Financial information may be collected in order to make arrangements for the payment of services.

We collect information from our clients about their health history, their family health history, physical condition, and dental treatments (collectively referred to as “medical information”). Client’s medical information is collected and used for the purpose of diagnosing dental
conditions and providing care Clients’ medical information is disclosed to other healthcare professionals:

Where we are seeking a second opinion.
Where the client, has been referred by us to a healthcare professional for treatment.
Where those professionals have asked us, to provide a second opinion.

If we are ever considering selling all or part of our practice, qualified potential purchasers may be granted access as part of the due diligence process to client information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure
that the prospective purchaser safeguards all personal information.

Dentists are regulated by the Alberta Dental Association which may inspect our records and interview our staff as part of it regulatory activities in the public interest.

I Consent to the collection, use and disclosure of my personal information as stated above.

Patient Name*

First Last

Signature*

Date*

Berlin Questionnaire

1. Do you snore?*

Yes
No
Don't know

1b. Your snoring is:*

Slightly louder than breathing
As loud as talking
Louder than talking
Very loud - can be heard in adjacent rooms

1c. How often do you snore?*

Nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or nearly never

1d. Has your snoring ever bothered other people?*

Yes
No
Don't know

1e. Has anyone noticed that you quit breathing during your sleep?*

Nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or nearly never

2. How often do you feel tired or fatigued after your sleep?*

Nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or nearly never

3. During your waking time, do you feel tired, fatigued or not up to par?*

Nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or nearly never

4. Have you ever nodded off or fallen asleep while driving a vehicle?*

Yes
No

4b. How often does this occur?*

Nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or nearly never

5. Do you have HIGH blood pressure?*

Yes
No

Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just 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. Use the following scale to choose the most appropriate reaction for each situation.

Sitting and Reading - Chance of Dozing - Chance of Dozing:*