Oral Appliance Therapy Annual Review Questionnaire Please complete the questionnaire below Patient Name Today's Date Today's Date D.O.B Family Physician Email Address Appliance Wear What percentage of nights per week are you wearing your appliance? What percentage of nights per week are you wearing your appliance? 100% More than 75% More than 50% More than 25% How many hours are you wearing your appliance each night? How many hours are you wearing your appliance each night? 100% More than 75% More than 50% More than 25% Have you made any further adjustments/turns to your appliance? Have you made any further adjustments/turns to your appliance? yes no If yes, how many? How satisfied are you with your appliance? How satisfied are you with your appliance? Very Moderately Mildly Not What would improve your satisfaction? Appliance Effects In the past few weeks, have you: Been Snoring? Been Snoring? yes no Been told you have stopped breathing/have been gasping for breath? Been told you have stopped breathing/have been gasping for breath? yes no Had morning fatigue/fogginess or have been waking feeling unrefreshed? Had morning fatigue/fogginess or have been waking feeling unrefreshed? yes no General Are you experiencing any discomfort preventing you from wearing your appliance? Are you experiencing any discomfort preventing you from wearing your appliance? yes no Are you aware of any problems structurally with your appliance? Are you aware of any problems structurally with your appliance? yes no If yes, please explain Additional comments or information about your appliance/therapy (optional) Submit
