If "Someone Else" please fill out the information below:
If "Yes" please enter your policy information below, beginning with your Primary Insurance Policy.
Primary Insurance Policy
Please list your preferred pharmacies in order of preference.
Please check all that apply.
If "Yes" please list all of your allergies to medicine(s).
If "Yes" please list any current medications you are taking.
Please list your healthcare providers, beginning with your primary care physician.
If you answered "Yes" and have had multiple studies, list the most recent one without a CPAP
We believe that sleep quality is a very important issue and often requires team approach. We will work closely with your sleep doctor and/or Primary care doctor. Are there any other health/wellness providers that you would like us to share your treatment progress with?
This questionnaire was developed to determine the level of daytime sleepiness in individuals. It has become one of the most frequently used methods for determining a person’s average level of daytime sleepiness.
Please rate how likely you are to doze or fall asleep in the following situations by selecting the response that best applies. If you have not done some of these activities recently, select what would most likely happen if you were in that situation.
Use the following scale to choose the most appropriate number for each situation:
It is important that you answer each question as best you can.
I understand if I answered Yes to the above questions, I am required to obtain from my physician the following:
By answering No to the above questions, I understand if my Medicare has for CPAP, BIPAP, oral appliance I may be responsible for my new appliance based upon the Same and Similar guidelines laid out by Medicare.
Your information will be encrypted.