Sleep Forms Patient Details

Sleep Forms Medical History

  •  Amoxicillin/Penicillin
  •  Aspirin
  •  Clindaymycin
  •  Codeine
  •  Erythromycin
  •  Hydrocodone
  •  Latex
  •  Local Anesthetics
  •  Acrylics
  •  Other
  •  Artificial Heart Valve
  •  Artificial Joint Replacement
  •  Asthma
  •  Cancer
  •  Chemotherapy/Radiation
  •  Chest Pains
  •  Congenital Heart Defect
  •  Epilepsy/Seizures
  •  Excessive Bleeding/Bruise Easily
  •  Emphysema/Bronchitis/COPD
  •  Diabetes
  •  Drug Abuse
  •  High Blood Pressure
  •  Hepatitis
  •  Heart Attack
  •  Stroke
  •  Heart Disease
  •  Pregnancy
  •  Sinus Problems
  •  Mood Disorders
  •  Tuberculosis
  •  Other
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Sleep Forms Dental History

Before making an oral sleep appliance we must evaluate your current oral health. This includes a set of 10 x-rays and a visual exam.   You do not need a decay-free mouth, but we do need to make sure your teeth have no mobility, your gums are generally stable, and that there are no current infections. 

If you are currently a patient of Dr. Trevino's then you will not need another exam or x-rays. 

Sleep Forms Xray Consent

I accept and agee that x-rays will need to be taken before airway screening is completed. 

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Sleep Forms Medical Insurance Info

Sleep Forms Informed Consent

Snoring and Obstructive Sleep Apnea (OSA) are both breathing disorders that occur during sleep due to narrowing or total closure of the airway.  Snoring is a noise created by the partial closure of the airway and may often be no more problematic than the noise itself.  However, consistent, loud, heavy snoring has been linked to medical disorders such as high blood pressure.  OSA is a serious condition where the airway totally closes many times during the night and can significantly reduce oxygen levels in the body and disrupt sleep.  In varying degrees, these can result in excessive daytime sleepiness, irregular heartbeat, high blood pressure and occasionally heart attack and stroke.  Because any sleep disordered breathing may potentially represent a health risk, all individuals are advised to consult with their physician or sleep specialist for accurate diagnosis of their condition before treatment can be started.

Oral appliances maybe helpful in the treatment of snoring and sleep apnea.  Those diagnosed with mild or moderate sleep apnea are better candidates for improvement with this therapy than those severely affected.  Oral appliances, that are designed to assist breathing by keeping the tongue forward, have substantially reduced snoring and sleep apnea for many people. There are no guarantees this therapy will be successful for every individual.  Several factors contribute to the snoring/apnea condition including nasal obstruction, narrow airway space in the throat, and excess weight.  Since each person is different and presents with unique circumstances. Oral appliances will not reduce snoring and/or apnea for everyone.  

Furthermore, some people may not be able to tolerate the appliance in their mouth.  Also, many individuals will develop temporary adverse side effects such as excess salivation, sore jaw joints, sore teeth, and a slight change in their bite that will diminish within an hour after appliance removal in the morning.  A morning repositioner has been made for you and this has to be used daily.  On a rare occasion, a permanent bite change may occur requiring restorative therapy.  It is advised that the oral appliance be checked at least twice a year to ensure proper fit and that the mouth be examined at the time to ensure a healthy condition. If any unusual symptoms occur, it is recommended that the appliance not be worn until an office visit is scheduled to evaluate the situation.  

Individuals who have been diagnosed with sleep apnea may notice that after sleeping with an oral appliance they feel more refreshed and alert during the day.  This is only subjective evidence of improvement and may be misleading.  The only way to accurately measure whether the appliance is keeping the oxygen level sufficiently high to prevent abnormal heart rhythms is to have a consultation and follow up sleep tests while wearing the appliance.  This is a must for apnea patients. 

I understand and agree that I am responsible for the following expenses: Any service my insurance plan deems "non-covered," all coinsurance and/or co-payment amounts, all deductibles, any amount that exceeds benefits under my plan and any amount my insurance plan deems not covered because I was not insured on the date of service.

Please sign below indicating that you have read and understand this information concerning oral appliances for the treatment of snoring and/or sleep apnea and that you are willing to accept any and all risks known and unknown involved. 

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Sleep Forms Intolerance Form

  •  I am claustrophobic
  •  I am unable to sleep with CPAP mask and equipment in place
  •  CPAP restricts movement during sleep
  •  CPAP causes distended stomach, burping, or irritated IBS symptoms
  •  The mask leaks
  •  I unconsciously remove the CPAP at night
  •  The noise from the device disturbs my sleep or my bed partner's sleep
  •  CPAP does not seem to be effective in reducing/eliminating my symptoms
  •  I have tried multiple masks and non are comfortable enough to use
  •  I develop sinus/ear/throat infections
  •  Cannot travel with CPAP
  •  Pressure on the upper lip causes gum/tooth related problems
  •  My job/lifestyle prevent nightly use (Army, Reserves, Truck Driver, etc)
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Sleep Forms Sleep Questionnaire

  •  High blood pressure
  •  Heart disease
  •  Diabetes
  •  Stroke
  •  Depression
  •  Sleep apnea
  •  Lung disease
  •  Insomnia
  •  Narcolepsy
  •  Nasal oxygen use
  •  Restless leg syndrome
  •  Morning headaches
  •  Sleeping medication
  •  Pain medication (ie vicodin, oxycontin)

How likely are you to doze off in the following situations?

Frequency of Events

***ATTENTION:  The severity of the answers you provide to the remaining questions are extremely important in determining whether your medical insurance will pay their portion of your sleep apnea treatment.

Sleep Forms Sleep Subjective

Sleep Forms Prior Diagnosis

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