New Patient Form

Snoring & Sleep Apnea Center of Greater New York
New Patient Form

Patient Information

Mr. Ms. Mrs. Dr.

First Name:

Last Name:

MI:

Home Phone ()

Cell Phone ()

Work Phone ()

Address:

City:

State:

Zip:

Email Address:

Date of Birth (M/D/Y): / /

Gender: M F

Social Security Number (SSN):

Height: Feet Inches

Weight (lbs):

Marital Status: Married Single Life Partner Minor

Spouse or Parent/Guardian (if minor) Name:

Emergency Contact:

Relationship:

Phone:

REFERRED BY:

Employer Information

Employer:

Phone: ()

Fax: ()

Address:

City:

State:

Zip:

Health Insurance Information

Patient's Relationship to Primary Insured: Self Spouse Child Other

Name of Insured (First, MI, Last):

Insured DOB (M/D/Y): / /

Insurance Co:

Insurance ID:

Group #:

Plan Name:

Business Address:

City:

State:

Zip:

Phone: ()

Fax: ()

Email:

Please present your insurance card so we can photocopy it.

Secondary Health Insurance Information

DO YOU HAVE SECONDARY INSURANCE? YES NO

IF YES, PLEASE COMPLETE THIS SECTION

Patient's Relationship to Primary Insured: Self Spouse Child Other

Name of Insured (First, MI, Last):

Insured DOB (M/D/Y): / /

Insurance Co:

Insurance ID:

Group #:

Plan Name:

Business Address:

City:

State:

Zip:

Phone: ()

Fax: ()

Email:

Please present your insurance card so we can photocopy it.

Snoring & Sleep Apnea Center of Queens and Nassau
New Patient Form

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:

FAX:

ADDRESS:

ENT:

PHONE:

FAX:

ADDRESS:

SLEEP DOCTOR:

PHONE:

FAX:

ADDRESS:

DENTIST:

PHONE:

FAX:

ADDRESS:

OTHER MD:

PHONE:

FAX:

ADDRESS:

OTHER MD:

PHONE:

FAX:

ADDRESS:

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

INITIAL:

Date:

Snoring & Sleep Apnea Center of Queens and Nassau
New Patient Form

EPWORTH SLEEPINESS SCALE

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

TOTAL =

THORNTON SNORING SCALE

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

TOTAL =

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

Do you have other complaints?

Frequent snoring

Excessive daytime sleepiness (EDS)

Difficulty falling asleep

Waking up gasping / choking

Morning headaches

Neck or facial pain

I have been told I stop breathing when I sleep

Other

Difficulty maintaining sleep

Choking while sleeping

Feeling unrefreshed in the morning

Memory problems

Impotence

Nasal problems, difficulty breathing through the nose

Irritability or mood swings

Subjective Signs and Symptoms

Rate your overall energy level

Rate your sleep quality

Have you been told you snore?

Rate the sound of your snoring

On average, how many times per night do you wake up?

On average, how many hours of sleep do you get per night?

How many times per night does you bedtime partner notice you stop breathing?

Snoring & Sleep Apnea Center of Queens and Nassau
New Patient Form

Have you ever had a sleep study? YES NO

If YES, where and when?

Date:

Have you tried CPAP? YES NO

Are you currently using CPAP? YES NO

If YES, how many nights per week do you wear it? / 7 Nights

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?

Mask leaks

An inability to get the mask to fit properly

Discomfort from the straps or headgear

Decreased sleep quality or interrupted sleep from CPAP device

Noise from the device disrupting sleep and/or bedtime partner's sleep

CPAP restricted movement during sleep

CPAP seems to be ineffective

Device causes teeth or jaw problems

A latex allergy

Device causes claustrophobia or panic attacks

An unconscious need to remove CPAP at night

Caused GI / stomach / intestinal problems

CPAP device irritated my nasal passages

Causes dry nose or dry mouth

The device causes irritation due to air leaks

Other

Are you currently wearing a dental device? YES NO

Have you previously tried a dental device? YES NO

If YES, was it Over The Counter (OTC)? YES NO

Was it fabricated by a dentist? YES NO

If YES, who fabricated it?

If applicable, please describe your previous dental device experience:

Have you ever had surgery for snoring or sleep apnea? YES NO

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.

Snoring & Sleep Apnea Center of Queens and Nassau
New Patient Form

PRE-MEDICATION - Have you been told you should receive pre-medication before dental procedures? YES NO

If YES, what medication(s) and why do you require it?

ALLERGENS -- Please list everything you are allergic to (for example: asprin, 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 example: heart attack, high blood pressure, asthma, stroke, hip replacement, HIV, dibetes, etc):

Dental History

How would you describe your dental health? EXCELLENT GOOD FAIR POOR

Have you ever had teeth extracted? YES NO

If YES, please describe

Do you wear removable partials? YES NO

Do you wear full dentures? YES NO

Have you ever worn braces (orthodontics)? YES NO

If YES, date completed

Does your TMJ (jaw joint) click or pop? YES NO

Do you have pain in this joint? YES NO

Have you had TMJ (jaw joint) surgery? YES NO

Have you ever had gum problems? YES NO

If YES, have you ever had gum surgery? YES NO

Do you have dry mouth? YES NO

Have you ever had an injury to your head, face, neck, or mouth? YES NO

Are you planning to have dental work done in the near future? YES NO

Do you clench or grind your teeth? YES NO

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

Family History

Have genetic members of your family had:

Have genetic members of your family been diagnosed or treated for a sleep disorder? YES NO

How often do you consume alchohol within 2-3 hours of bedtime? Daily Occasionally Rarely/Never

How often do you take seditives within 2-3 hours of bedtime? Daily Occasionally Rarely/Never

How often do you consume caffeine within 2-3 hours of bedtime? Daily Occasionally Rarely/Never

Do you smoke? YES NO

If YES, how many packs per day?

Do you use chewing tobacco? YES NO

If YES, how many times per day?

PATIENT SIGNATURE

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:

Date:

Snoring & Sleep Apnea Center of Queens and Nassau
New Patient Form

Assignment of Benefits

I request that payment of authorized insurance benefits, including Medicare if I am a Medicare Beneficiary, be made either to me or on my behalf to the organization listed below for any equipment or services provided to me by that organization. I hereby assign and convey directly to the below-named health care provider ("Provider"), as my designated authorized representative, all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services, treatments, therapies, and/or medications rendered or provided by the Provider, regardless of its managed care network participation status.

I understand that I am financially responsible to the Provider for any charges regardless of health care benefits. It is my responsibility to notify the Provider of any changes in my health care coverage. In some cases exact insurance benefits cannot be determined until the insurance company receives the claim. I am responsible for the entire bill or balance of the bill as determined by the Provider and/or my health care insurer if the submitted claims or any part of them are denied for payment.

I hereby authorize the Provider to release all medical information necessary to process my claims. Further, I hereby authorize my plan administrator fiduciary, insurer, and/or attorney to release to the Provider any and all plan documents, summary benefit description, insurance policy, and/or settlement information upon written request from the Provider or its attorneys in order to claim such medical benefits.

In addition, I also assign and/or convey to the Provider any legal or administrative claim or choose an action arising under any group health plan, employee benefits plan, health insurance or tort feasor insurance concerning medical expenses incurred as a result of the medical services, treatments, therapies, and/or medications I receive from the Provider (including any right to pursue those legal or administrative claims or choose an action). This constitutes an express and knowing assignment of ERISA breach or fiduciary duty claims and other legal and/or administrative claims. I intend by this assignment and designation of authorized representative to convey to the Provider all of my rights to claim (or place a lien on) the medical benefits related to the services, treatments, therapies, and/or mediations provided by the Provider, including rights to any settlement, insurance or applicable legal or administrative remedies (including damages arising from ERISA breach of fiduciary duty claims). The assignee and/or designated representative (Provider) is given the right by me to (1) obtain information regarding the claim to the same extent as me; (2) submit evidence; (3) make statements about facts or law; (4) make any request including providing or receiving notice of appeal proceedings; (5) participate in any administrative and judicial actions and pursue claims or choose in action or right against any liable party, insurance company, employee benefit plan, health care benefit plan, or plan administrator. The Provider as my assignee and my designated authorized representative may bring suit against any such health care benefit plan, employee benefit plan, plan administrator or insurance company in my name with derivative standing at Provider's expense.

Unless revoked, this assignment is valid for all administrative and judicial reviews under PPACA (health care reform legislation), ERISA, Medicare and applicable federal and state laws. A photocopy of this assignment is to be considered valid, the same as if it was the original.

PROVIDER: K Scott Danoff, DMD, 49-33 Little Neck Parkway, Little Neck, NY 11362

Patient Signature
I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT.

Print Name:

Patient / Guardian Signature:

Date:

Snoring & Sleep Apnea Center of Queens and Nassau
New Patient Form

AFFIDAVIT FOR INTOLERANCE TO CPAP

I have attempted to use the nasal CPAP to manage my sleep related breathing disorder (apnea) and find it intolerable to use on a regular basis for the following reasons:

Mask Leaks

An inability to get the mask to fit properly

Discomfort or interrupted sleep caused by the presence of the device

Noise from the device disturbing sleep or bed partner’s sleep

CPAP restricted movements during sleep

CPAP does not seem to be effective

Pressure on the upper lip causes tooth related problems

Latex allergy

Claustrophobic associations

An unconscious need to remove the CPAP apparatus at night

Other

Because of my intolerance/inability to use the CPAP, I wish to have an alternative method of treatment. That form of therapy is oral appliance therapy (OAT).

Print Name:

Signature:

Date:

Patient Validation:

Before You Submit!

Please double-check that the above information is correct.
It is highly recommended that you print a copy of your form and bring it with you to the appointment if possible.

Everything Look Good?