Snoring & Sleep Apnea Center of Queens and Nassau
New Patient Form
Patient Information
Mr. Ms. Mrs. Dr.
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/ /
M F
Morning Mid-Day Evening
Home Phone Cell Phone Work Phone
Married Single Life Partner Minor
Employer Information
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Health Insurance Information
Self Spouse Child Other
/ /
()
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Please present your insurance card so we can photocopy it.
Secondary Health Insurance Information
YES NO
IF YES, PLEASE COMPLETE THIS SECTION
Self Spouse Child Other
/ /
()
()
Please present your insurance card so we can photocopy it.
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.
 
 
 
 
 
I certify this information is true, accurate, and complete to the best of my knowledge.
EPWORTH SLEEPINESS SCALE
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 = No chance of dozing
1 = Slight chance of dozing
2 = Moderate chance of dozing
3 = High chance of dozing

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

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
(Low) 1 2 3 4 5 6 7 8 9 10 (Excellent)
(Low) 1 2 3 4 5 6 7 8 9 10 (Excellent)
YES NO SOMETIMES
(Quiet) 1 2 3 4 5 6 7 8 9 10 (Loud)
NEVER RARELY SOMETIMES OFTEN EVERYDAY
YES NO SOMETIMES
YES NO
How many times per night does you bedtime partner notice you stop breathing?
SEVERAL TIMES PER NIGHT ONCE PER NIGHT SEVERAL TIMES PER WEEK OCCASIONALLY SELDOM NEVER
YES NO
YES NO
YES NO
/ 7 Nights
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
YES NO
YES NO
YES NO
YES NO
If applicable, please describe your previous dental device experience:
YES NO
Please list any nose, palatal, throat, tongue, or jaw surgeries you have had.
Please comment about any other therapy attempts (weight loss, gastric bypass, etc.) and how each impacted your snoring and apnea and sleep quality.
YES NO
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
EXCELLENT GOOD FAIR POOR
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
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:
YES NO
YES NO
YES NO
YES NO
Daily Occasionally Rarely/Never
Daily Occasionally Rarely/Never
Daily Occasionally Rarely/Never
YES NO
YES NO
PATIENT SIGNATURE
I certify that the information I have completed on these forms is true, accurate, and complete to the best of my knowledge.
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.

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

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).

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