Saving Lives & Relationships
DENTIST/ HYGIENIST REFERRAL FORM
WA Phone:
(425) 565-1872
| CA-Phone :
(951) 579-0842
| Email :
info@zapzzz.com
Patient's Full Name:
DOB:
Patients Phone Number:
Insurance Name:
Insurance Medical ID number:
Group/Policy #
Address, City, State, and Zip:
1) STOP-BANG Section
Snoring
Do you Snore Loudly (loud enough to be heard through closed doors or your bed- partner elbows you for snoring at night)?
YES
NO
Tired?
Do you feel tired, fatigued, or sleepy during the daytime (such as falling asleep during driving or talking to someone)?
YES
NO
Observed?
Has anyone observed you stop breathing or choking/gasping during your sleep?
YES
NO
Pressure?
Do you have or are you being treated for high blood pressure?
YES
NO
BMI
Body Mass Index more than 35 kg/m^2 (Completed by DR/HYG ONLY)
cm/kg
inches/Ib
HEIGHT
WEIGHT
CALCULATED BMI
YES - Body Mass Index MORE than 35 kg/m^2
NO - Body Mass Index LESS than 35 kg/m^2
Age?
Age older than 50?
YES
NO
Neck size large? (Measured around Adam's apple) (Completed by DR/HYG ONLY)
Is pts shirt collar 16 inches / 40cm or larger?
YES
NO
Gender:
MALE
FEMALE
OSA - LOW RISK : YES TO 0 - 2 QUESTIONS
OSA - INTERMEDIATE RISK : YES TO 3 - 4 QUESTIONS
OSA - HIGH RISK : YES TO 5 - 8 QUESTIONS
Or Yes to 2 or more of 4 STOP questions + male gender
Or Yes to 2 or more 4 STOP questions + BMI > 35kg/m^2
Or YES to 2 or more 4 STOP questions + neck circumference 16 inches / 40cm
TOTAL SCORE FOR PT
2) Relevant Medical History
Please check any that are applicable
Stroke or TIA
Atrial fibrillation or other arrhythmia
COPD or asthma
Hypothyroidism
Depression or anxiety
ADHD
Use of alcohol or sedatives
3) Patient Sheet Questions
1. Does the patient suffer from recurring/morning headaches?
Yes
No
2. Does the patient suffer from jaw pain?
Yes
No
3. Does the patient grind or clench their teeth?
Yes
No
4. Does the patient have dry mouth?
Yes
No
5. Does the patient gasp for air?
Yes
No
6. Does the patient have a history of Diabetes/ Heart Conditions?
Yes
No
7. Does the patient have a history of High Blood Pressure?
Yes
No
8. Has the patient been diagnosed with Sleep Apnea before?
Yes
No
Patient referred to: Dental Sleep Specialist – ZapZzz Sleep Center
Provider Referral Info
Referring Doctors Name:
NPI:
Providers Signature:
Date:
Practice Name:
Office Phone Number:
Address, City, State, and Zip:
Practice Email:
Reason for Study/ Additional Information:
Submit
