Patient Forms

Patient Registration

Please fill in completely

Marital Status:
 Single Married Married Widowed Separated Domestic Partner Divorced and Remarried
Is there usually a bed partner to observe your sleep?
 Caucasian Asian Hispanic African American Other

Primary Insurance Information

Policy Holder:

Secondary Insurance Information

Policy Holder:
Present Dentist
Primary Care Physician:
Sleep Physician/Pulmonologist:
Ear Nose Throat (ENT) Physician:

Records Release: I hereby authorize Aspen Ridge Sleep Solutions and Dr. Jared Waite to release my information, including diagnosis and records of treatment concerning my past medical history, to my referring physician/dentist or other pertinent health care providers, insurance company and immediate family.

Patient Signature: Date:

Medical History

Do you have or have you had any pain in any of the following areas?
 Jaw Ear Face Neck Teeth Headachesother 
Does your jaw make any of the following noises?
 Clicking Popping Rubbing Grinding Crunchingother 
Have you received treatment for any TMJ, head, or neck symptoms?
When was your last dental visit?
Have you been told that you have periodontal (gum) disease?
Do you have any existing problems with your teeth (please describe)?
Is any dental treatment planned?

What is your present occupation?

Do you work shifts? If so, which shifts?
Do you smoke?
 yes no
If so, for how many years?
How frequently?
Do you drink alcohol?
If so, how many drinks per week?
Is there anyone in your family with the following conditions
 Narcolepsy Dementia Excessive Sleepiness Insomnia Sleep Apnea
Please circle all below occurrences that either you or someone else has observed of you:
 Snoring Acting Out Dreams Wake Up Gasping For Air Leg Jerks Nighttime Wheezing Stop Breathing While Sleeping Restless Sleep Vivid Dreams/Nightmares Take Sleeping Medication Talking in Sleep Morning Headaches Creeping/Crawling Feeling in Legs Teeth Grinding Sleep Disrupting Ideas Feel the Need to Move Your Legs Sleep Walking Awaken with Dry Mouth Pain the Interferes with Sleep
Please fill in your current sleep schedule:
Bedtime: a.m./p.m. Rise Time:  a.m./p.m.
How long does it take you to fall asleep?
Days Off
Bedtime: a.m./p.m. Rise Time: a.m./p.m.
How long does it take you to fall asleep?
Do you have any difficulty falling asleep at night?
If yes, please explain:
How many hours, on average, do you sleep per night?
Do you have difficulty breathing through your nose?
Have you gained weight recently?
About how much?
What is your current weight?
ft. in.
Have you had your tonsils removed?
If so, at what age?
List any surgeries you have had and years you had them:

Please circle any of the following that apply to your personal medical history:


 Change in Appetite Fever General Weakness Marked Weight Change Night Sweats Polyuria (frequent urination) Recent Trauma or Injury Unusual Weakness Chronic Fatigue Syndrome Hepatitis Tumors/cancer HIV/AIDS


 Anaphylactic Reaction Dairy Dust Excessive Sneezing Hay Fever Latex Penicillin Sulpha Drugs Wheat


 Confusion Dizziness Fainting Memory Loss Muscle Weakness Seizures Stroke Tingling/Numbness Tremor Alzheimer’s Disease Multiple Sclerosis (MS)


 Acne Frequent Bleeding Bruising Eczema Itch Lesions Psoriasis


 Diabetes Gout Hormonal Changes Thyroid Problems

Eyes, Ears, Nose and Throat

 Change in Hearing Change in Smell Dysphagia (difficulty swallowing) Ear Pain Glaucoma Hearing Loss Hoarseness Nasal Discharge Sinus Problems Tinnitus (ringing in ears) Visual Changes Nasal Obstruction Nose Bleeding


 Coronary Artery Disease Chest Pain Congestive Heart Failure Heart Attack Heart Murmur High Blood Pressure High Cholesterol Irregular Heart Beat Tachycardia (rapid heart beat)


 Asthma Bronchitis Chest Pressure Colored Sputum Congestion Cough Dyspnea (shortness of breath) Emphysema Hemoptysis (cough up blood) Hypoventilation Syndrome Orthopnea (short of breath while supine) Pneumonia Pulmonary Embolism Shortness of Breath Tuberculosis


 Black or Bloody Stool Constipation Diarrhea GERD Irritable Bowel Syndrome Stomach Pain Ulcers Vomiting


 Frequent Urination Hematuria (blood in urine) Incontinence Kidney Infection Kidney Stones Kidney Disease Prostate Problems Cervical/Uterine/Ovarian Cancer Breast Cancer Currently Pregnant


 ADD/ADHD Anxiety Autism Depression Disorientation Excess Stress Hallucination Memory Problems Eating Disorders Chemical Dependency


 Back Pain Fibromyalgia Joint Pain Limited Range of Motion Muscle Atrophy Muscle Pain

List any medications you are taking and dosage, including over the counter:
I certify that the above information is correct to the best of my knowledge.
Patient/Guardian Signature:
DDS Signature:

The Epworth Sleepiness Scale

Your Age (years):
Your Sex:
 Male Female
How likely are you to doze off or fall asleep in the following situation, 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.
Use the following scale to choose the most appropriate number for each situation.
O = would  never doze
1 =  slight chance of dozing
2 = moderate chance of dozing
3 =  high chance of dozing
Situation: Chance of Dozing
Sitting and reading
Watching TV
Sitting, inactive in a public place (e.g. theater or meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after lunch without alcohol

Sleep Questionnaire

Patient Name
Reason for oral appliance evaluation
How long have you had this problem
What other doctors have you seen about your snoring or sleep apnea?
What professional advice or treatment have you received about your snoring or sleep apnea?
Have you had a sleep lab study?
What were the results?
If you snore, what sleeping positions do you snore in (circle all that apply)?
 Back Side Stomach
Does your snoring disturb others?
What positions do you sleep in the most?
 Back Side Stomach
Check any of the following that you do while you are in bed?
 Read Eat Watch TV Do Work Activities Sleep with the TV on
How many times per night do you wake up per night?
Have you been told you move around a lot while asleep?
Has your snoring/sleep apnea caused problems for relatives or friends?
How many times do you wake to use the restroom?
How long does it take you fall back to sleep after a restroom visit?
If you have difficulty falling asleep, what do you do?
Do you take naps?
Are the naps refreshing?
Do you exercise?
If yes, what time of day do you exercise?

Rate the following situations you’ve experienced during the past week:

Have you snored or have you been told that you do?
 1 2 3 4
Have you had choking or shortness of breath sensations at night?
 1 2 3 4
Have you woken up during sleep?
 1 2 3 4
Have you had morning fatigue or fogginess or woken up feeling unrefreshed?
 1 2 3 4
Have you woken up with a headache?
 1 2 3 4
Have you had chronic sleepiness, fatigue or weariness that you can’t explain?
 1 2 3 4
Have you fallen asleep during the day, particularly when not busy?
 1 2 3 4
Have you fallen asleep reading or watching television?
 1 2 3 4
Have you fallen asleep during the day against your will?
 1 2 3 4
Have you had to pull off the road while driving due to sleepiness?
 1 2 3 4
Have you been more irritable and short-tempered?
 1 2 3 4
Have you felt your memory and/or intellect is impaired?
 1 2 3 4
Have you been told that you stop breathing while asleep?
 1 2 3 4

Bed Partner Questionnaire

To be completed by the patient’s bed partner, without influence of the patient. Please complete and have the patient bring with him/her to consultation with Dr. Waite.
Patient’s Name:
Relationship to Patient:
Sleep Schedule Hours of sleep per night? How long does it take your partner to fall asleep? How long is your partner awake during the night?
Days Off:
Circle any positions your bed partner sleeps in:
 Back Side Stomach
Does your bed partner snore?
 Never Occasionally Often Unknown
If he/she snores, please circle the positions when snoring is most common:
 Back Side Stomach
How loud is his/her snoring?
 1(light) 2 3 4 5(loud)
Does your bed partner do any of the following in his/her sleep?
 Gagging Choking Snorting Gasping Teeth Grinding Kicking Feet
Does your bed partner take naps during the day?
 Never Occasionally Occasionally Unknown
Does your partner stop breathing in his/her sleep?
 Never Occasionally Occasionally Unknown
Does your bed partner fall asleep when driving?
 Never Occasionally Occasionally Unknown
Does he/she fall asleep without warning?
 Never Occasionally Occasionally Unknown
Does your bed partner kick their legs while sleeping?
 Never Occasionally Occasionally Unknown
Does your bed partner mumble, talk, or yell during sleep?
 Never Occasionally Occasionally Unknown
Does your bed partner awaken during the night?
 Never Occasionally Occasionally Unknown
If he/she awakens, how long does it take him/her to get back to sleep?
Hrs: min:
Do you know why he/she awakens
If yes, why?
Is your bed partner restless during sleep?
 Never Occasionally Occasionally Unknown
Describe what he/she does when restless:
How much stress does your bed partner currently have?
 1 (light) 2 3 (a lot) Unknown
Please estimate your bed partner’s risk of falling asleep or doing off in the following situations, using the following scale: 0 = No chance, 1 = Slight chance, 2 = Moderate chance, 3 = High chance
Sitting and reading:
 1 2 3 4
Lying down to rest in the afternoon:
 1 2 3 4
Watching TV:
 1 2 3 4
As a passenger in a car for an hour with no break:
 1 2 3 4
Sitting inactive in public (i.e. theater, meetings)
 1 2 3 4
Sitting quietly after lunch, without alcohol
 1 2 3 4
Sitting and talking to someone
 1 2 3 4
In a car, stopped in traffic, for a few minutes
 1 2 3 4
Has your bed partner’s mood, memory, concentration, or personality deteriorated or changed?
If yes, please explain:
Does your bed partner’s sleep problems disrupt your sleep?
 Never Occasionally Often
Please explain:
Please use this space for any other information you would like to add.