Dr. Charles R. Verbanic D.D.S

127 Churchill Hubbard Rd, Youngstown, OH, 44505

(330) 759-4550

New Patient Form

Patient Information

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Employer Information

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Health Insurance Information

Patient's Relationship to Primary Insured:
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Secondary Health Insurance

DO YOU HAVE SECONDARY INSURANCE?:

IF YES, PLEASE COMPLETE THIS SECTION

Patient's Relationship to Primary Insured:
Name of Insured (First, MI, Last):
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Medical Contacts

Dental Sleep Solutions® coordinates treatment with your other medical providers to ensure maximum benefit to you. Where applicable, please list your other medical providers.

PRIMARY CARE DOCTOR: Phone:
ENT: Phone:
SLEEP DOCTOR: Phone:
DENTIST: Phone:
OTHER MD: Phone:
OTHER MD: Phone:

I certify this information is true, accurate, and complete to the best of my knowledge.


INTIAL:
DATE:

Patient Questionnaire

EPWORTH SLEEPINESS SCALE

0=No chance of dozing, 1=Slight Chance of dozing, 2=Moderate Chance of dozing, 3=High Chance of dozing

Sitting and reading 0 1 2 3
Watching TV 0 1 2 3
Sitting inactive in public place (theater) 0 1 2 3
As a car passenger for an hour without a break 0 1 2 3
Lying down in the afternoon to rest 0 1 2 3
Sitting and talking to someone 0 1 2 3
Sitting quietly after lunch without alcohol 0 1 2 3
In a car while stopped at a traffic light 0 1 2 3
TOTAL:

THORNTON SNORING SCALE

0=Never, 1=1 night/week, 2=2-3 nights/week, 3=4+ nights/week

My snoring affects my relationship with my partner 0 1 2 3
My snoring causes my partner to be irritable or tired 0 1 2 3
My snoring requires us to sleep in separate rooms 0 1 2 3
My snoring is loud 0 1 2 3
My snoring affects people when I am sleeping away from home 0 1 2 3
TOTAL:

Please list the main reason(s) you are seeking treatment for snoring or sleep apnea

Do you have other complaints?

Subjective Signs And Symptoms

Rate your overall energy level:
(Low)   (Excellent)
Rate your sleep quality:
(Low)   (Excellent)
Have you been told you snore?:
Rate the sound of your snoring:
(Quiet)   (Loud)
On average, how many times per night do you wake up?
On average, how many hours of sleep do you get per night?
How often do you awaken with headaches?:
Do you have a bed partner?:
Do you sleep in the same room?:
How many times per night does your bedtime partner notice you stop breathing?
Have you ever had a sleep study?
If YES, where and when?
Date
Have you tried CPAP?
Are you currently using CPAP?
If YES, how many nights per week do you wear it? (/7nights)
When you wear your CPAP, how many hours per night do you wear it?(hours per night)

If you use or have used CPAP, what are your chief complaints about CPAP?

Are you currently wearing a dental device?
Have you previously tried a dental device?
If YES, was it Over the Counter (OTC)?
Was it fabricated by a dentist?
If YES, who fabricated it?
If applicable, please describe your previous dental device experience:
Have you ever had surgery for snoring or sleep apnea?

Please list any nose, palatal, throat, tongue, or jaw surgeries you have had.

DATE:
SURGEON:
SURGERY:
DATE:
SURGEON:
SURGERY:
DATE:
SURGEON:
SURGERY:

Please comment about any other therapy attempts (weight loss, gastric bypass, etc.) and how each impacted your snoring and apnea and sleep quality.

PRE-MEDICATION- Have you been told you should receive pre-medication before dental procedures?
If YES, what medication(s) and why do you require it?

ALLERGENS - Please list everything you are allergic to (for example: aspirin, latex, penicillin, etc):

MEDICATIONS - Please list all medications you are currently taking:

MEDICAL HISTORY - Please list all medical diagnoses and surgeries from birth until now (for exam pie: heart attack, high blood pressure, asthma, stroke, hip replacement, HIV, diabetes, etc):

Dental History

How would you describe your dental health?
Have you ever had teeth extracted?
If YES, please describe
Do you wear removable partials?
Do you wear full dentures?
Have you ever worn braces (orthodontics)?
If YES, date completed
Does your TMJ (jaw joint) click or pop?
Do you have pain in this joint?
Have you had TMJ (jaw joint) surgery?
If YES, have you ever had gum surgery?
Do you have dry mouth?
Have you ever had an injury to your head, face, neck, or mouth?
Are you planning to have dental work done in the near future?
Do you clench or grind your teeth?

If you answered YES to any question above, please briefly describe your answer here:

Family History

Have genetic members of your family had:

Heart Disease?
High Blood Pressure?
Diabetes?
Have genetic members of your family been diagnosed or treated for a sleep disorder?
How often do you consume alcohol within 2-3 hours of bedtime?
How often do you take sedatives within 2-3 hours of bedtime?
How often do you consume caffeine within 2-3 hours of bedtime?
Do you smoke?
If YES, how many packs per day?
Do you use chewing tobacco?
If YES, how many times per day?

I certify that the information I have completed on these forms is true, accurate, and complete to the best of my knowledge.

Patient or Guardian Signature

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Date

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