Dr. Halstrom | Forms - Patients - Dr. Halstrom

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Treating Sleep Apnea and Snoring Since 1994
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Latest News

Obstructive sleep apnea during REM sleep & blood pressure.

Obstructive sleep apnea during REM sleep: effects on morning and evening blood pressure. This new...

March 11th, 2023

Fantastic New Device – SomnoDent Avant

Dr. Halstrom is happy to report that our recent results using the SomnoMed Avant device are simply...

January 13th, 2023

Forms – Patients

TELE-CONSULT REGISTRATION FORM

Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Phone
Date of Birth [MMDDYYYY]
Month
Day
Year
PHN - Care Card Number
Gender
Name of Spouse / Partner
Do you have a dental plan?
- Yes
- No
Do you have an Extended Health Insurance Plan?
- Yes - My Own Plan Only
- Yes - Spouses / Partner Plan Only
- Yes - Double Coverage Own Plan & Spouse Partner Plan
- No
If yes to insurance: Spouse / Partner Date of Birth [MMDDYYYY]
Month
Day
Year
Name of Primary Extended Health Insurance Company
Plan or Group Number - Primary Plan
Plan ID Number - Primary Plan
Plan Member's Employer - Primary Plan
Name of Secondary Extended Health Insurance Company
Plan or Group Number - Secondary Plan
Plan ID Number - Secondary Plan
Plan Member's Employer - Secondary Plan
Previous Sleep Testing and/Or Treatment - check all applicable:
- I have had a home sleep test.
- I have had a sleep test in hospital / sleep lab.
- I have done a CPAP trial only.
- I have purchased a CPAP.
- I am unable to tolerate CPAP.
- I have had surgery for snoring - sleep apnea.
- I have had an oral appliance - over the counter.
- I have had an oral appliance - professional.
Previous Sleep Testing Diagnosis - if applicable.
- Mild Sleep Apnea
- Moderate Sleep Apnea
- Severe Sleep Apnea
Sleep Questionnaire - complete if no previous sleep test:
- I Do Snore Loudly (loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night).
- I have been Observed to Stop Breathing or Choking/Gasping during sleep.
- I often feel Tired, Fatigued, or Sleepy during the daytime (such as falling asleep during driving or talking to someone).
- I have and/or am being treated for high blood pressure.
Health Conditions - check all applicable.
- Stroke
- Heart Attack / Angina
- AFIB
- Low Thyroid
- Erectile Dysfunction
- Congestive Heart Failure
- Diabetes / Kidney Disease
- Chronic Depression
Additional Symptoms during sleep suggesting Apnea - check all applicable.
- Broken Sleep
- Acid Reflux
- Irregular Heartbeat
- Night Sweats
- Excess Urination
- Headaches
- Teeth Grinding / Clenching
Do you have dentures?
Regular Dental Appointments?
Any loose / sore teeth or gum disease?
Do you have any dental implants?
Have you ever been diagnosed with jaw pain issues – TMJ problems?
Weight - Pounds
Height - Inches
Please enter a number from 1 to 200.
Family Dentist Name
Family Dentist City
Family Physician Name
Family Physician - City
Family Physician - Clinic Name
How did you first hear about us:*
- Google - Web Search
- Bing - Web Search
- Other - Web Search
- MD Referral
- Dentist Referral
- Patient Referral
- Other
Name of person who referred you (if applicable)?
Other Notes
Consent*
- Yes
- No
I authorize contact and sharing of this information with my physician, dentist, medical specialist and extended health benefits provider.

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About Dr. Halstrom

With a great deal of good fortune I was able to walk away from a serious single car accident. Following the accident I was diagnosed with sleep apnea. I tried CPAP therapy unsuccessfully, as I was unable to accommodate to the daily requirements of wearing the mask....Read More

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