Jeremy J. Abbott, DDS  – Sleep Apnea, TMJ  Specialist Sleep Apnea Doctor – TMJ Disorders
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  • Wildwood Medical Center | Bethesda, Maryland
 
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Home   Health History Form

 

Health History Form

Step 1 of 15

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  • 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
 
 
 
 

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