Snore Centre New Patient Form

Medical History
Name*
First Last
Date of Birth:*
YYYY dash MM dash DD
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?*
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
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?
YYYY dash MM dash DD
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
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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*
YYYY dash MM dash DD
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:*
- 0 - Never
- 1 - Slight
- 2 - Moderate
- 3 - High
Watching TV - Chance of Dozing - Chance of Dozing:*
- 0 - Never
- 1 - Slight
- 2 - Moderate
- 3 - High
Sitting, inactive in a public place (e.g. a theater or a meeting) - Chance of Dozing:*
- 0 - Never
- 1 - Slight
- 2 - Moderate
- 3 - High
As a passenger in a car for an hour without a break - Chance of Dozing:*
- 0 - Never
- 1 - Slight
- 2 - Moderate
- 3 - High
Lying down to rest in the afternoon when circumstances permit - Chance of Dozing:*
- 0 - Never
- 1 - Slight
- 2 - Moderate
- 3 - High
Sitting and talking to someone - Chance of Dozing:*
- 0 - Never
- 1 - Slight
- 2 - Moderate
- 3 - High
Sitting quietly after a lunch without alcohol - Chance of Dozing:*
- 0 - Never
- 1 - Slight
- 2 - Moderate
- 3 - High
In a car, while stopped for a few minutes in traffic - Chance of Dozing:*
- 0 - Never
- 1 - Slight
- 2 - Moderate
- 3 - High
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Total Score
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Medical History

The Snore Centre Personal Information Consent Form

Berlin Questionnaire

Epworth Sleepiness Scale