(301) 530-8570
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6010 Executive Blvd. Suite 500
Rockville, MD 20852
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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
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Date of Birth
*
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Weight
Address
*
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West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Mobile Phone Number
*
Other Phone Number
*
Email
*
How did you find us?
Doctor Referral
Found us on the internet
Other
If other, please describe below:
Medical Insurance
*
Dental Insurance
Referring Doctors
*
Referring Doctor and other Doctors you would like to have reports sent to. Please include their full name and address.
Primary Care Physician’s Name, address and phone number
Pharmacy Name and Phone #:
Allergies (if No Known Allergies type N/A) List all allergies to medications and the reaction you had to any medicine (or any other allergies):
Understanding Your Sleep Complaint:
Describe in your own words the sleep problem(s) you would like help with:
Do you snore?
Yes
No
Do you have insomnia?
Yes
No
If yes, explain:
Have you been told that you stop breathing while you sleep?
Yes
No
Do you suddenly wake up gasping for breath during the night?
Yes
No
Do you kick or have been told that you kick during the night?
Yes
No
Do you have daytime fatigue?
Yes
No
Do you nap during the day?
Yes
No
Do you have morning headaches?
Yes
No
Do you wake up feeling tired?
Yes
No
Do you have difficulty at work because of sleepiness?
Yes
No
Do you have trouble remembering things or concentrating during the day?
Yes
No
Do you have high blood pressure?
Yes
No
Does your bed partner have a sleep problem?
Yes
No
N/A
If yes, explain:
In general, into which category or categories below would your sleep problem best fit? (check all that apply)
Snoring
Excessive sleepiness or fatigue
Difficulty getting to sleep
Difficulty staying asleep
Abnormal or unusual behavior
Other
Is your sleep problem:
Continuous
Intermittent
If your sleep problem is intermittent, how often does it occur?
Several times a month
Several times a week
Every day
What makes your sleep WORSE? Be Specific.
What makes your sleep BETTER? Be Specific
When did your sleep problem start?
When did your sleep become problematic?
What do YOU think is the cause of your sleep problem?
Indicate which of the following treatments you have tried for your sleep problem:
Dental device
Medications
CPAP
Surgery
Behavioral therapy
Other
If other, please describe
List all current and previous medications you have taken for sleep problems:
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
Sitting and reading
0
1
2
3
Watching TV
0
1
2
3
Sitting, inactive, in a public place (theater, meeting, etc.)
0
1
2
3
As a passenger in a car for an hour without a break
0
1
2
3
Lying down to rest in the afternoon when circumstances permit
0
1
2
3
Sitting and talking to someone
0
1
2
3
Sitting quietly after a lunch without alcohol
0
1
2
3
In a car, while stopped for a few minutes in traffic
0
1
2
3
Have you ever been evaluated at a sleep center? If Yes, List the Doctors Name:
List ALL doctors you have seen for your sleep problem:
Do you have jaw problems?
Yes
No
Do you have jaw pain?
Yes
No
Do you have clicking or other noises in your jaw joint(s)?
Yes
No
Do you have difficulty opening or closing your mouth?
Yes
No
Please describe any jaw or face problem(s) that you may have:
Is nausea associated with your pain?
Yes
No
Is vomiting associated with your pain?
Yes
No
Does your pain increase with bright lights?
Yes
No
Does your pain increase with bright lights?
Yes
No
Does your pain increase with loud noises?
Yes
No
Does physical activity make your pain:
Better
Worse
No Change
Do you get an aura (flashing lights, zigzags, blindness, smells)?
Yes
No
If yes, describe:
Does your pain wake you from sleep?
Yes
No
Does your pain keep you from falling asleep?
Yes
No
Do any of your family members have the same or similar pain problem?
Yes
No
Do any of these occur with your pain:
Eyelid drooping
Redness of the eye(s)
Tearing of the eye(s)
Face sweating
Is your pain:
Continuous
Intermittent
If your pain is intermittent how often does it occur?
Several times a day
Once per day
Several times a week
Once per week
Less than once per week
Never
Other
How long does your pain last?
Seconds
Minutes
Hours
Days
Weeks
Continuous
CURRENT MEDICATIONS: List ALL medicines you are CURRENTLY taking for medical and pain problems
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
When did your pain start?
When did your pain became a problem?
How many times did you go to the emergency room for pain in the past year?
What event or events led to your present pain:
Accident
Cancer
Surgery
Other injury
Other disease
No Obvious Cause
Other
What do YOU think is the cause of your pain?
List ALL the doctors you have seen for your pain problem
Please include: Date, Name, Specialty, Address, and Phone Number
Please list, in chronological order, all tests and X-Rays performed to evaluate your pain:
Diagnostic tests (MRI. CT SCANS, X-RAYS, CLOOD TESTS, ETC). Please include Date, Test, and the Result
Indicate which of the following treatments you have tried for your problem:
Antidepressants
Acupuncture
Psychotherapy
Homeopathy
Narcotics
Chiropractor
Biofeedback
TENS
Nerve blocks
Massage
Relaxation training
Exercise program
Traction
Physical therapy
Hypnosis
Other
If other, please describe:
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):
A. General
Weight loss
Poor appetite
Severe fatigue/ low energy
Cancer
B. Hematologic
Anemia
Easy Bruising
Bleeding disorder
Taking blood thinners
Blood transfusion
C. Skin
Rash
Nail changes
Bumps / nodules
D. Head and Neck
Headaches
Visual Changes
Mouth problems
Neck Pain
TMJ problems
E. Cardiac
Exercise limitations
Chest pain
Irregular heartbeat
Heart murmur
High or low blood pressure (circle one)
Circulation problems
Ankle swelling
F. Pulmonary
Shortness of breath
Cough
Asthma or bronchitis
Lung disease
Sleep Apnea
Snoring
G. Endocrine
Diabetes
Thyroid problems
H. Gastrointestinal
Abdominal pain
Nausea or vomiting (circle)
Constipation
Diarrhea
History of ulcers or heartburn (circle)
I. Genitourinary
Frequent or hesitant urination (circle)
Pain with urination
Blood in urine
Incontinence
Sexual dysfunction
J. Musculoskeletal
Arthritis
Osteoporosis
Muscle pain
Muscle wasting
Fractures
What Type of Arthritis
Where Do You Have Fractures
K. Neurologic
Numbness
Weakness
Falling
Stroke
Seizures
Memory loss
Loss of balance
L. Infectious Diseases
Measles
Mumps
Chicken Pox
Rheumatic Fever
Hepatitis
HIV / AIDS
Herpes
Shingles
Post-herpetic neuralgia
What Type of Hepatitis
Herpes Location
M. Gynecologic
Pregnant
Post-Menopausal
When Were You Pregnant
When Was Your Last Period
Medical Problems: Please indicate any other medical problems that are not listed above.
Do you exercise?
Yes
No
How many days per week do you exercise?
How long do you exercise each time (on average)?
Family Medical History
Father Age
Father Deceased or Living
Father Medical Problems
Mother Age
Mother Deceased or Living
Mother Medical Problems
Siblings Age
Sibling Deceased or Living
Sibling Medical Problems
Spouse Age
Spouse Medical Problems
Spouse Deceased or Living
Relationship Status
Single
Significant other
Married
Separated
Divorced
Widowed
Highest Level of Education Completed
GED
High school
Vocational
College
Graduate
Other
If Other Please Describe
List the name of the person or person’s you live with and their relationship to you.
What is your current employment status?
Your current or most recent occupation:
Are you on disability?
Do you or have you smoked tobacco?
Yes
No
Number of Packs per day:
Previous smoker?
Years smoked:
Any alcohol use?
Yes
No
How many drinks per week?
Do you use recreational drugs?
Yes
No
Type:
Do you drink Coffee/Tea/Caffeine?
Yes
No
Number of Cups or drinks per day:
Do you have any legal action pending related to this pain or any other health issue?
Yes
No
If yes, please list the attorney’s name, address, and phone number:
Describe your mood:
Do you have problems with any of the following?
Concentration
Anxiety
Depression
Motivation
Sleep
Self-Worth
Homicidal thoughts
Suicidal thoughts
Appetite
Are you currently in therapy?
Yes
No
If Yes, Name:
How often do you see them?
Do you have a history of physical or mental abuse?
Yes
No