(301) 530-8570
Call Us Now
6010 Executive Blvd. Suite 500 Rockville, MD 20852
  • Home
  • Meet Dr. Jeremy Abbott
  • New Patients
    • Patient Portal
    • Temporomandibular joint dysfunction and What You Can Do
    • Sleep Apnea & Snoring
  • Oral Devices
    • Types of Oral Devices
    • Dental Appliance vs. CPAP Machines
    • Do Oral Appliances Work for Sleep Apnea?
    • Can My Bite Change If I Use An Oral Sleep Apnea Device?
    • Can I Use an Oral Sleep Apnea Device if I Have a TMJ Disorder?
  • Insurance
  • Forms
  • Payment
  • Contact Us
Menu
  • Home
  • Meet Dr. Jeremy Abbott
  • New Patients
    • Patient Portal
    • Temporomandibular joint dysfunction and What You Can Do
    • Sleep Apnea & Snoring
  • Oral Devices
    • Types of Oral Devices
    • Dental Appliance vs. CPAP Machines
    • Do Oral Appliances Work for Sleep Apnea?
    • Can My Bite Change If I Use An Oral Sleep Apnea Device?
    • Can I Use an Oral Sleep Apnea Device if I Have a TMJ Disorder?
  • Insurance
  • Forms
  • Payment
  • Contact Us

Health History Form

Step 1 of 15

6%
  • MM slash DD slash YYYY
  • Referring Doctor and other Doctors you would like to have reports sent to. Please include their full name and address.
  • Describe in your own words the sleep problem(s) you would like help with:
  • Epworth Sleepiness Scale: How likely are you to doze off or fall asleep in the following situations, 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 the situation: 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing
  • Including prescribed, over-the-counter, herbs, and vitamins. Also, be sure to include: Name. Strength, Number of Times Per Day, Prescribing Doctor, and Date Started
  • Please include: Date, Name, Specialty, Address, and Phone Number
  • Diagnostic tests (MRI. CT SCANS, X-RAYS, CLOOD TESTS, ETC). Please include Date, Test, and the Result
  • Review of Systems Please check if you currently or have ever had any of the following (please indicate next to the item when the problem occurred):
  • Family Medical History

We Are Here to Help You

Contact Info

6010 Executive Blvd. Suite 500

Rockville, MD 20852

(301) 530-8570
[email protected]

Don't Suffer Through Another Sleepless Night

(301) 530-8570

Make An Appointment

Copyright © 2022 Jeremy J. Abbott, DDS – Sleep dentist. All Rights Reserved

Rockville, Maryland sleep apnea doctors, dentists leading specialists in sleep apnea, tmj disorders, temporomandibular joint dysfunction, oral facial pain, serving Virginia, VA, MD, Washington DC.