PATIENT INFO - Elite Dental Group
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New Patient Information

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New Patient Registration Forms

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Claims/ Dental and Personal Accident Insurance

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Brochures

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PDPA / NEHR

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Information for Foreign Patients

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Cancellations/ No Show Policy/ Booking Deposits

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Dental Emergencies

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Consent Forms & Information Sheets

 YOUR SLEEP QUESTIONNAIRE

STOP BANG




Snoring - Has anyone ever mentioned you snore loudly?

Tired - Do you often feel tired, fatigued or sleepy during the daytime?
Observation - Has anyone ever observed you stop breathing during your sleep?
Blood Pressure - Have you got high blood pressure?
BMI - Are you overweight?
Age - Are you over 50 years old?
Neck - Is your neck circumference greater than 40cm?
Gender - Are you male?


GENERAL QUESTIONS


Do you feel refreshed when you wake after 7 hours sleep?

Has anyone in your family ever been diagnosed with Obstructive Sleep Apnea?
Have you been diagnosed or are you being treated for depression?
Have you been diagnosed with type 2 diabetes?
Do you wake often during the night to go to the bathroom?
Do you suffer with headaches upon waking?


EPWORTH SLEEPINESS SCORE


For each situation listed below, circle a number from 0 to 3 that best reflects how likely you are to fall asleep. Be as realistic as you can.


0 – No chance of falling asleep 1 – Slight chance of falling asleep     2 –Good Chance of falling asleep 3 – High chance of falling asleep



Sitting and reading
Watching TV
As a passenger in a car for an hour
Lying down in the afternoon
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car stopped while in traffic
× How can I help you today?