New Patient Form | Elevate Oral & Jaw Surgery Kogarah

Name

Today's Date

Phone

Date of Birth

Sex (M/F)

Age

Enquiry

Do you have a referral?

Yes No

Medical History

Do you have any medical conditions?

Yes No

If yes, please list

Are you taking any medications?

Yes No

If yes, please list

Do you have any allergies?

Yes No

If yes, please list

Have you had any previous surgeries?

Yes No

If yes, please describe

Radiographs (if available)

Do you have sleeping problems or concerns?

Yes No

If yes, please complete the Sleep Concern Evaluation Forms. If none, please click ‘No’ and submit your form.

Sleep-Concern Evaluation Forms

To help us assess your sleep concerns, please fill out the following questionnaires if you're here for possible obstructive sleep apnoea.

Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired?

This refers to your usual way of life in recent times. Even if you haven't 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 each situation:

0 = would never doze I = slight chance of dozing 2 = moderate chance of dozing 3= high chance of dozing

It is important that you answer each question as best you can.

Sitting and Reading

Watching TV

Sitting, inactive in a public place (e.g. a theatre or a meeting)

As a passenger in a car for an hour without a break

Lying down to rest in the afternoon when circumstances permit

Sitting and talking
to someone

Sitting quietly after a lunch without alcohol

In a car, while stopped for a fcw minutes in the traffic

Snoring Severity Scale

Please fill out this scale together with the help of a family member, or with someone who lives with you and regularly observes your sleep, as they can provide the most accurate assessment of your snoring.

How often do you snore?

Every Night Most (>50%) of nights Some (<50%) of nights Very rarely or not at all

How long do you snore?

All Night Most (>50%) of nights Some (<50%) of nights Hardly or not at all

How audible is your snoring (with the door shut)?

Can be heard down the hall Can be heard in the next room Can be heard in the same room Barely audible

New Patient Registration

For Patients

Questions?

Hours

Where to Find Us

Monday	8:30 AM – 4:30 PM
Tuesday	8:30 AM – 4:30 PM
Wednesday	8:30 AM – 4:30 PM
Thursday	8:30 AM – 4:30 PM
Friday	Closed
Saturday	Closed
Sunday	Closed