Dr. Darrell Morden, Dr. Dawna Wetherell

1107-37th St. SW Calgary, AB T3C 1S5

(403) 242-5777

SLEEP-RELATED BREATHING DISORDER CONSULTATION

Dr. Darrell Morden DDS Diplomate, American Board of Dental Sleep Medicine


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Date

How did you hear about Our Clinic?



PERSONAL INFORMATION

Mr. Ms. Mrs. Dr. First
Last
Phone
Email
Date of Birth:
Age:
Best Tele Number:
Home Address:
Family Physician/Walk-in:
AHS Care #:
Family Dentist/Clinic:
Specialist Doctors:
Pharmacy:

As applicable


CHIEF COMPLAINTS / REASONS FOR CONSULTATION

SLEEP CENTRE EVALUATION(S)

Previous Sleep Clinic or Sleep Physician evaluation(s)?
If yes, list Clinic/Doctor
Year
Overnight study

Diagnosis List



If an ENT / Surgeon consulted for sinus/airway concerns? Name

Previous Insomnia / Cognitive-behavioral interventions?
Where:

THERAPY ATTEMPTS

CPAP (CONTINUOUS POSITIVE AIRWAY PRESSURE) HISTORY

I did a trial of CPAP
I purchased a CPAP device

Year:

Location:
If in use, average hours/night worn
I sleep better using CPAP?
I feel more refreshed the next morning having used CPAP
Last use of the machine:
I tried different types like
I tried different masks/interfaces like
Current CPAP Pressure Setting:

CPAP INTOLERANCE / PROBLEMS

SLEEP HISTORY / NORMAL HABITS

Normal bedtime:
Normal wake-up time:
Time takes to fall asleep: min/hr
Times awakened at night:
Difficulty returning to sleep?
Typical time it takes to return to sleep min/hr
Do you dream

Sleep aid / medication?
Napping

Awakenings/Interrupted sleep caused by:

DAYTIME SLEEPINESS PROBLEMS (EPWORTH SLEEPINESS SCALE)

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

(Even if not a recent thing, think on how they would have affected you in these specific examples)

0=No Chance, 1=Possibly, 2=Would have, 3=Yes definitely

Sitting and reading 0 1 2 3
Watching TV / Movie 0 1 2 3
Sitting inactive (Meeting, Theatre) 0 1 2 3
As a passenger a car for an hour 0 1 2 3
Lying down to rest in the afternoonpermit 0 1 2 3
Sitting and talking to someone 0 1 2 3
Sitting quiet after lunch, no alcohol 0 1 2 3
In a car, stopped in traffic 0 1 2 3


SOCIAL HISTORY

Occupation/Vocational Training


Alcoholic beverage Daily Weekly Rarely Never Before Sleep Problematic History
Caffeine beverage Daily Weekly Rarely Never Before Sleep Problematic History
Nicotine/replacement Daily Weekly Rarely Never Before Sleep Problematic History
CBD/THC/Marijuana Daily Weekly Rarely Never Before Sleep Problematic History
Evening consumption Alcohol Caffeine Nicotine CBD/THC Food
SHIFT WORK?

SLEEP DEPRIVATION

MEDICAL HISTORY


Does History include:


CURRENT MEDICATIONS


SLEEPING PILLS

HERBAL/ALTERNATIVES

ALLERGENS


SURGERIES

FAMILY MEDICAL HISTORY

Mother health concerns:
Father's health concerns:

CLINIC USE

HT iN cm
WT lb kg
BMI


MALLAMPATI   /   /   /  

/   /  

/  

Number of teeth

/  

Neck Circ in cm
O2SAT
BP


/  

/  

/   /  

/   /  

Gag Reflex report

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