Oral Appliance Therapy Annual Review Questionnaire

Patient Name

Today's Date

DOB

Family Physician

Your email

Appliance Wear
What percentage of nights per week are you wearing your appliance?
100%>75%>50%>25%

How many hours are you wearing your appliance each night?
100%>75%>50%>25%

Have you made any further adjustments/turns to your appliance?
yesno

If yes, how many?

How satisfied are you with your appliance?
VeryModeratelyMildlyNot

What would improve your satisfaction?

Appliance Effects
In the past few weeks, have you:
Been snoring?
yesno

Been told you have stopped breathing/have been gasping for breath?
yesno

Had morning fatigue/fogginess or have been waking feeling unrefreshed?
yesno

General
Are you experiencing any discomfort preventing you from wearing your appliance?
yesno

Are you aware of any problems structurally with your appliance?
yesno

If yes, please explain

Additional comments or information about your appliance/therapy (optional)