Affidavit for Intolerance to CPAP

    I have attempted to use the nasal CPAP to manage my sleep related breathing disorder (apnea) and find it intolerable to use on a regular basis for the following reason(s):

    Because of my intolerance / inability to use the CPAP, I wish to have an alternative method of treatment. That form of therapy is oral appliance therapy (OAT).

    The EPWORTH Sleepiness Scale

    How likely are you to doze off or fall asleep in the following situations?

    Y/ Check one in each row


    No chance







    Sitting and Reading


    Watching TV

    Sitting inactive in a public place (e.g. a theater or a meeting)

    Lying down to rest in the afternoon when circumstances permit

    Sitting and talking to someone

    Sitting quietly after lunch without alcohol

    In a car, while stopped for a few minutes in traffic

    What are the chief complaints for which you are seeking treatment?

    Please number the complaints with #1 being the most important

    I have been told that I "stop breathing" when sleeping:

    Morning headaches:

    Difficulty falling asleep:

    Gasping when waking up:

    Swelling in ankles or feet:

    Nighttime choking spells:

    Nocturnal teeth grinding:

    Feeling unrefreshed in the morning:

    Jaw pain:

    Facial pain:

    Jaw clicking:

    Morning hoarseness:


    Your History

    Family History

    1.Have any members of your family (blood kin) had:

    Heart Disease

    High Blood Pressure


    2.Have any immediate family members been diagnosed or treated
    for a sleep disorder? Yes

    Do you use chewing tobacco?

    I authorize the release of a full report of examination findings, diagnosis, treatment programs, etc. to any referring or treating dentist or physician. I additionally authorize the release of any medical information to insurance companies or for legal documentation to process claims. In understand that I am responsible for |all fees for treatment regardless of insurance coverage.

    I understand that the only way to measure the efficacy of an intraoral sleep apnea appliance is via follow-up polysomnography, which I agree to do following fitting and adjustments.