Health History Form E-mail; Today's Date:

American Dental Association \vw\v.ada.org

As required by law, our off ice adheres to w n t t e n policies and procedures to protect the privacy o f i n fo rma t i on about you that w e create, receive or mainta in . Your answers are for our records only and wi l l be kept conf ident ia l subject t o appl icable laws. Please note tha t you w i l l be asked some quest ions about your responses t o this quest ionnaire and there may be addi t iona l quest ions concern ing your hea l th . This i n fo rma t ion is vital to a l low us to provide appropr ia te care for you . This of f ice does n o t use this i n fo rma t ion t o discr iminate.

t^ame.

Last Address:

Wailing address Occupation:

First Middle

Home Phone: include area code

( ) City:

Height: Weight:

Business/Cell Phone: include area code

( ) State: Zip:

Date of bir th: Sex: M

SS# or Patient ID: Emergency Contart : Relationship: Home Phone: Cell Phone:

( ) ( ) Include area codes

If you are comp le t ing this f o r m for another person, wha t is your relat ionship to that person?

Your Name Do you have any of the fo l lowing diseases or problems:

Act ive Tuberculosis

Rel^TiOnshtp

(Check DK if you Don't Know the artswer to the question) Y e s N o DK • • •

Persistent cough greater than a 3 week dura t ion • • • C o u g h that produces b lood • • • Been exposed to anyone with tuberculosis • • • If you answer yes to ar)y of the 4 items above, please stop and return this form to the receptionist.

Dental In format ion For the followng auesrions please mark (X) your responses to the following questions.

Do your gums bleed w h e n you brush or floss? • • •

Are your teeth sensitive to co ld , hot , sweets or pressure? • • •

Does f o o d or floss catch be tween your teeth? • • •

Is your m o u t h dry? • • •

Have you had any per iodonta l (gum) t reatments? • • •

Have you ever had o r thodon t i c (braces) t rea tment? • • •

Have you had any problems associated w i th previous dental

treatment? • • •

Is your home water supply f luor idated? • • •

Do y o u dr ink bo t t l ed or f i l tered .vater^ • • •

If yes, h o w of ten? Circle one: DAL- .-.'EEKLY / OCCASIONALLY

Are you current ly experiencing di'-'a' c : - ?r d scomfort? • • •

W h a t IS the reason fo r your denta i . i S t : c - 5 ; •

Y e s N o D K

Do you have earaches or neck pains? • • •

Do you have any c l icking, pepp ing or d iscomfor t in the j aw? • • •

Do y o u brux or g r ind your teeth? • • •

Do you have sc^es „:ce's ,n your mouth ? • • •

Do yoL ! >• J : ' ~ ; ' t - ' e s or part-c;';^ • • •

Do y o L c s r - z o r . e -n active recreatona l activities? • • •

Have yo,. e . e - n s d a serious injury t o your head or m o u t h ? • • 13

Date o ! / c^ ' iast dental exam:

Wha t ••is c-'? at that t ime?

D i : e c - ==: a e r i a l x-rays;

H o w do you feel about your smile?

Medical In format ion Please mark . X tCur ^esc-onse to indi

Y e s N o D K Are you n o w under the care of a physician? L-. J L

Physician Name: Phone: include area code

( )

Address/City/State/Zip:

Are you in g o o d health? • • •

Has there been any change in your general health w i th in the past year? • • •

If yes, w h a t cond i t i on is being treated?

ate if you have or have not had any of the following diseases or problems.

Y e s N o OK

Have you had a serious lilness, opera t ion or been hospital izeo in the past 5 years? • • •

If yes, w h a t was the illness or problem?

Are you taking or have you recently taken any prescription or over the counter medicine(5)? • • •

If so, please list all. i n c l u d n g v i tamins, natural or herbal preparat ions and/or diet supplements ;

Date of last physical exam;

© 2(X)7 American Dental Association Form S500

v U : ' ! I i j : ! n i O t n 1<;: ! <J Please mark (X)your response to indicate if you have or have not had any of the following diseases or problems.

(Check DK if you Don't Know the answer to ttie question) Yes No DK Do you wear contact lenses? • • •

Joint Replacement. Have you had an or thoped ic tota l jo in t (hip, knee, e lbow, f inger ) replacement? • • • Date: If yes, have you had any complicat ions?

Are you tak ing or scheduled t o begin t ak ing either of the medications, alendronate (Fosamax*) or risedronate (Aaone l * ) fo r osteoporosis or Paget's disease? • • •

Since 2 0 0 1 , were you treated or are you presently scheduled to begin t rea tment w i t h the intravenous bisphosphonates (Aredia*" or Zometa " ) for bone pain, hypercalcemia or skeletal compl ica t ions result ing f r o m Pagefs disease, mul t ip le mye loma or metastat ic cancer? • Date Treatment began:

A l l e r g i e s - Are you allergic t o or have you had a react ion t o ; To all yes responses, specify type of r e a a i o n . Local anesthetics Aspir in Penicillin or o ther ant ibiot ics Barbiturates, sedatives, or sleeping pills Sulfa drugs

Yes No DK Do you use contro l led substances (drugs)? • • •

Do you use tobacco (smoking, snuff, chew, bidis)? • • • If so, h o w interested are you in stopping?

(Cirde one) VERY / SOMEWHAT / NOT INTERESTED

Do you dr ink alcoholic beverages? • • • If yes, h o w much alcohol did you dr ink in the last 24 hours? If yes, h o w much do you typically dr ink In a week?

W O M E N ONLY Are you ; Pregnant? Number of weeks:

• • •

• •

Yes No DK

Taking b i r th contro l pills or ho rmona l replacement? • • (11 Nursing? • • •

Metals Latex (rubber) Iodine

Codeine or o ther narcotics .

Hay fever/seasonal Animals Food Other

Yes No DK

. • • •

. • • •

. • • •

. • n • _ n • • . • • • . • • •

Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems. Yes No DK Yes No DK Yes No DK

Artificial (prosthetic) heart valve Previous infective endocarditis Damaged valves in transplanted heart Congenital heart disease (CHD)

Unrepaired, cyanotic CHD Repaired (completely) in last 6 months . Repaired CHD wi th residual defects

Except for the conditions listed above, entibiotic proptiylaxis is no longer recommenaed for any other form of CHD

Yes No DK Cardiovascular disease. . . Angina Arteriosclerosis Congestive heart failure Damaged heart valves Heart attack Heart murmur Low blood pressure High blood pressure Other congenital heart

defeas

Yes No DK ~ . U Mitral valve prolapse • • U

Z • Pacemaker .- • • • Z • Rheumatic fever • • • Z • Rheumatic heart disease • • • _ • Abnormal bleeding • • • Z • Anemia • • • ~ • Blood transfusion • • • Z • If yes, date: :Z U Hemophilia • • •

AIDS or HIV infection • • • • • Arthntis • • •

Auto immune disease • Rheumatoid arthritis • Systemic lupus erythematosus. • -j-.-na • E ;-chitis • Erchysema • S;r.j5 trouble • Ttbe'culosis • Cancer.'Chemotherapy/

r t lon Treatment Z

C ' r f c e m upon exertion ~ Cr ; • : oain Z

D'azi-.i; Type i or I I . . . ~ Ea: -0 a.sorder Z

t-jts;,- j f t ' o n Z

Gas-.'C '••estinal disease • - .ypersT-te-^

r s - T - j m • Ui:e-: • Th;,-: - C'-cbe-s • Stroi-e, • G l a _ ; : ~ 3 •

• • • • • • • • n • • a • • • z

• • • • • • • • n n

• • • • • • • • • •

Hepatitis, jaundice or liver disease • • •

Epilepsy • rZ •

Fainting spells or seizures • • • Neurological disorders • • •

If yes, specify: Sleep disorder • • • Mental health disorders • • •

Specify: • • • Recurrent Infections

Type of infection: Kidney problems • • • Night sweats • [11 •

Osteoporosis U • •

Persistent swollen glands in neck • • •

Severe headaches/ migraines O • •

Severe or rapid weight loss • • • Sexually transmitted disease.... • • • Excessive urination • • •

Has a physician or prev ic .s rent is t r ecommended : . :ake antibiot ics prior to y : c£--sl t rea tment? • • •

Name of physician or d e n ; i ; : ^->aking r e c o P ' " ' £ ^ z r : Phone;

Do you have any disease, cond i t ion , or p rob lem n o t listed above 'r.a: you th ink I should k n o w about? • • • Please explain;

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I cert ify tha t 1 have read and understand the above and that the in format ion given on this f o rm is accurate. I understand the importance of a t ru th fu l health history and tha t my dentist and his/her staff '.vill re'y on th>s n f o r m a i i o n for t reat ing me. I a cknowledge that my quest ions, if any abou t inquir ies set f o r t h above have been answered to my sat isfact ion, i -•.ji r,:: -zz ^ . -aentist, or any other member of his/her staff, responsible for any act ion they take or do n o t take because of errors or omissions that I may have m^ace tne complet ion of this f o r m .

Signature of Patient/Legal Guardian; Date:

FOR C O M P L E T I O N BY DENTIST

Comments : .

R O B E R T M. BAGOFF, D.M.D., L L C 405 Northfield Avenue, Suite 202 West Orange, New Jersey 07052

(973) 325-9000 (973) 325-3182 Fax

w\vw.ThcUnDentist(rt)gmail.coin

FINANCIAL POLICY

m O R D E R T O S E R V E Y O U B E T T E R , W E A S K T H A T A L L T H E F I N A N C I A L I N F O R M A T I O N B E C O M P L E T E D P R I O R T O S E E E S G T H E D O C T O R .

Regarding your bill/insurance -

P A Y M E N T I S E X P E C T E D A T T H E T I M E O F S E R V I C E . Payment plans are available. Financing is also available. Please see one of the front desk staff to assist you in the most convenient choice.

Your bill is your responsibility. Your insurance policy is a contract between you and your carrier. W E A R E N O T P A R T Y T O T H A T C O N T R A C T . Preauthorizations are N O T and absolute agreement by your insurance carrier to pay the amount shown. It is an estimation of benefits ( E O B ) only. This is C L E A R L Y stated on the form the insurance carrier sends you.

We will A L W A Y S send your insurance forms within 24 hours. We D O N O T charge A N Y additional fee to fdl out these forms. I f your insurance carrier has the service available, we will send the claims E L E C T R O N I C A L L Y via the Internet within 24 hours of the service billing date.

When you have paid your bill, all insurance forms are C L E A R L Y M A R K E D P A Y T O P A T I E N T . I f your carrier C H O O S E S N O T T O P A Y Y O U , please C A L L T H E M and register your complaints!!!!!!!!

We will provide you with a treatment plan for dental work to be done. A copy will be given to your and one will remain in your chart. We ask that you sign this document. This O N L Y shows that the plan was presented and is in N O W A Y an obligation to do the treatment.

We are A L L committed to providing you with the best treatment that we can. We wish all our arrangements to be as C L E A R as possible. I f you should have A N Y questions, please do not hesitate to ask at your earliest convenience.

Thank you for understanding our O F F I C E F I N A N C I A L P O L I C Y .

I have read this document and agree to the O F F I C E F I N A N C I A L P O L I C Y .

Signature Date

PATIENT INFORMATION

When registering, please present proof of insurance. 24 hour notice is required for cancellations. Service fee may be applied if less than 24 hour

notice is given. Payment is expected at the time of service.

PLEASE PRINT j j ^ j g . I / T I T L E : (Ms., Mrs., Mr., Miss, Dr.).

FIRST NAME:.

ADDRESS:

C I T Y :

LAST N AME x

ST: ZIP:.

BIRTH DATE: / / SOCIAL SECURITY #: l_

HOME PHONE #: ( ) - WORK PHONE #: ( ) _

C E L L PHONE #: ( ) - PAGER #: ( )

E-MAIL ADDRESS:

MAY WE C A L L TO CONFIRM YOUR FUTURE APPOINTMENTS?

WHAT IS THE BEST WAY TO R E A C H YOU? _

HOW DID YOU HEAR ABOUT OUR OFFICE? . —

YES NO

SPOUSE/GUARDIAN:

RELATIONSHIP: PHONE #: C

ADDRESS: •

C I T Y : _ _ _ ST- ZIP:

EMPLOYER: PHONE ft( )

PATIENT INFORMATION

R E S P O N S I B L E P A R T Y (if other than patient or guardian)

A D D R E S S :

C I T Y :

E M P L O Y E R :

S O C I A L S E C U R I T Y #: / /

S T : Z I P :

P H O N E #:( )

E M E R G E N C Y C O N T A C T : .

A D D R E S S :

C I T Y :

P H O N E #:( )

S T : Z I P :

P A T I E N T ' S E M P L O Y E R :

A D D R E S S :

C I T Y :

P H O N E #:( )

S T : Z I P :

P A Y M E N T M E T H O D : C A S H

M C / V I S A / A M E X / D I S C O V E R #:

C H E C K C R E D I T C A R D

E X P I R A T I O N D A T E :

PATIENT INFORMATION

I N S U R A N C E C O M P A N Y :

I N S U R A N C E C O . A D D R E S S :

C I T Y : S T : Z I P :

P H O N E #:( ) - P O L I C Y #:

I N S U R E D ' S A D D R E S S :

G R O U P #: N A M E O F I N S U R E D :

C I T Y : S T : Z I P :

D A T E O F B I R T H : / / P H O N E #:( ) - _

I N S U R E D ' S S O C I A L S E C U R I T Y #: - -

O T H E R I N S U R A N C E :

I N S U R A N C E C O . A D D R E S S :

C I T Y : S T : Z I P :

P H O N E #:( ) - P O L I C Y #:

G R O U P #:

I certify the above information is correct to the best of my knowledge. I also understand that I am financially responsible for all charges whether or not covered by insurance.

S I G N A T U R E : D A T E :

ROBERT M. BAGOFF, D.M.D., LLC 405 Northfield Avenue, Suite 202 West Orange, New Jersey 07052

(973) 325-9000 (973) 325=3182 Fax

www.TheU?iOentistcom

NOTICE OF PRIVACY PRACTICES

This notice describes how health information about you may be used and disclosed and how you can get access to this information.

Please review it carefully. The privacy of your health information is important to us.

OUR L E G A L DUTY

We are required by applicable federal and state law to maintain the pr ivacy of yo ur health information, We are also required to give y o u this Notice about our privacy practices, our legal duties, and your rights concerning your health i n f o r m a t i o n . We must fo l low the privacy practices that are described in this Notice w h i l e it is in effect. Tlt is notice takes immediately and w i l l remain in effect u n t i l we replace it.

We reserve the r ight to change our privacy practices and the terms of this Not ice at any time, provided said changes are p e r m i t t e d by applicable law. We reserve the r ight to make the changes in our privacy practices and tlie new terms of our Notice effective for all health i n f o r m a t i o n that we maintain, including health informat ion w e created or received before we made the changes. Before we make a significant change in our privacy practices, we can change this Notice and make the n e w Notice available upon request.

You may request a copy of our Notice at any time. For more Informat ion about our privacy practices or for additional copies of this Notice, please contact us using the i n f o r m a t i o n listed at the end of this Notice.

USES A N D D I S C L O S U R E S OF H E A L T H I N F O R M A T I O N

We use and disclose health i n f o r m a t i o n about you for treatment, payment and healthcare operations. For example:

Treatment: We may use or disclose your health informat ion to a physician or other healthcare provider provid ing treatment to y o u .

Payment; We may use and disclose y o u r health informat ion to obtain payme nt for services we provide to }'0U.

Healthcare Operat ions : We may use and disclose your health i n f o r m a t i o n in connechon w i t h our healthcare operations. Healthcare operations include qual i ty assessment and improvement activities, reviewing the competence of qualifications of healthcare professionals, evaluat ing practitioner and provider performance, conduct ing tra ining programs, accreditation, certif ication, licensing or credentialing activities.

Your Authorization; I n a d d i t i o n to our use of your health i n f o r m a t i o n for treatment, payment or healthcare operations, y o u may give us wri t ten authorization to use your health information or disclose it to anyone for any purpose. If y o u give us an authorization, y o u may revoke it i n w r i t i n g at any time. Your revocation w i l l not affect any use or disclosures permitted by y o u r authorizat ion while i t was in effect. Unless you give us a w r i t t e n authorization, we cannot use or disclose your health information for any reason except those described i n this Notice.

To Your Family and Friends; We must disclose your health in format ion to you , as described in the Patient Rights section of this Notice. We may disclose your health i n f o r m a t i o n to a family member, friend or another person to the extent necessary to help you w i t h your healthcare or w i t h payment for your healthcare, but on ly i f y o u agree that we may do so.

Persons Involved I n Care: We may use or disclose health i n f o r m a t i o n to not i fy , or assist in the notification of ( i n c l u d i n g i d e n d f y i n g or locating) a family member, y o u r personal representative or another person responsible for your care, of your location, your general condi t ion , or death. If you are present, then pr ior to use or disclosure of your health informat ion, we w i l l provide you w i t h an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we w i l l disclose health information based on a determinat ion using our professional judgment disc-losing o n l y healthcare informat ion that is directly relevant to the person's involvement in your healthcare. We w i l l also use our professional judgment and our experience w i t h common practice to make reasonable inferences of your best interest i n a l lowing a person to pick u p fi l led prescriptions, medical supplies, x-rays or other similar forms of health informat ion.

M a r k e t i n g Health -Related Services: We w i l l not use your health informat ion for marketing communications w i t h o u t your w r i t t e n authorization.

Required by Law; W e may use or disclose your health informat ion w h e n we are required to do so by law.

Abuse or Neglect; We may disclose your health information to appropriate authorities if we reasonable believe that you are a possible v i c t i m of abuse, neglect, or domestic violence or the possible vict im of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security; We may disclose to mil i tary authorihes the health in format ion of Armed Forces personnel under certain circumstances, We may disclose to authorized federal officials heath information required for l a w f u l intelligence, counterintelligence, and other national security activities. We may disclose to correctional inst i tvit ion or law enforcement official having lawh. i l custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders; We may use or disclose your heath information to provide you w i t h appointment reminders (such as voicemail messages, postcards, or letters).

P A T I E N T R I G H T S

Access: You have the r i g h t to look at or get copies of your health i n f o r m a t i o n , w i t h l i m i t e d exceptions, You may request that w e p r o v i d e copies in a format other than photocopies. We w i l l use the format you request unless w e cannot practicably do so. (You must make a request in w r i t i n g to obtain access to your health in format ion . Y o u may obtain a f o r m to request access by su ing the contact in format ion listed at the end of this Not ice . W e w i l l charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice, I f y o u request copies, w e w i l l charge y o u $1.00 for each page for staff rime to locate and copy your health information, and postage if y o u w a n t the copies mai led to y o u . If y o u request an alternative format, we w i l l charge a cost-based fee for p r o v i d i n g your health in format ion i n that format . I f y o u prefer, we w i l l prepare a summary or an explanat ion of your health i n f o r m a h o n for a fee. Contact us using the informat ion listed at the end of this Not ice for a f u l l explanation of our fee structure.)

Disclosure A c c o u n t i n g : Y o u have the r ight to receive a list of instances i n w h i c h w e or our business associates disclosed y o u r heath i n f o r m a t i o n for purposes, other than treatment, payment, healthcare operations and certain other activities for the last 6 years, but not before A p r i l 14, 2003. If y o u request this accounting more than once i n a 12 m o n t h per iod, we may charge y o u a reasonable, cost-based fee for responding to these a d d i t i o n a l requests.

Restriction; You have the r i g h t to request that we communicate w i t h y o u about yo ur health informahon

by alternative means or locat ion, and p r o v i d e satisfactory explanation h o w payments will be handled

under the alternadve means or locat ion y o u request.

Amer tdment : You have the r ight to request that we amend yo ur health i n f o r m a t i o n . (Your request must be i n w r i t i n g and i t m u s t expla in w h y the informat ion should be amended.) W e may deny your request under certain circumstances.

Electronic Not ice : If y o u receive this Notice on our Web site or by electronic mai l (e-mail), y o u are entitled to receive this N o t i c e in w r i t t e n f o r m .

Q U E S T I O N S A N D C O M P L A I N T S

If you want more i n f o r m a t i o n about our privacy practices or have questions or concerns, please contact

us.

I f you are concerned that w e may have violated your pr ivacy rights, or y o u disagree w i t h a decision we made about access to y o u r heal th i n f o r m a t i o n or i n response to a request y o u made to amend or restrict the use of disclosure o f y o u r health i n f o r m a t i o n or to have us communica te w i t h y o u by alternative means or at alternative locations, y o u may complain to us using the contact i n f o r m a t i o n listed at the end of this notice. You also may s u b m i t a w r i t t e n complaint to the U.S. D e p a r t m e n t of H e a l t h and H u m a n Services. We w i l l p r o v i d e y o u w i t h the address to file your compla in t w i t h the U.S. Department of Health and H u m a n Services u p o n request.

We support your r ight to the privacy of your health information. We w i l l not retaliate in any way if you choose to file a complaint w i t h us or w i t h the U.S. Department of Health and H u m a n Services.

ROBERT M. BAGOFF, D.M.D., LLC 405 Northfield Avenue, Suite 202 West Orange, New Jersey 07052

(973) 325-9000 (973) 325-3182 Fax

www.ThellnDentlsLcom

ROBERT M. BAGOFF. D.M.D.. LLC 405 Northfiefd Avenue, Suite 202 West Orange, New Jersey 07052

(973) 325-9000 (973) 325-3182 Fax

www.TheUnDentisLcom

A C K N O W L E D G E M E N T OF RECEIPT OF NOTICE OR PRIVACY PRACTICES

^'^^^You may refuse to Sign this Acknowledgement****

I , , have received a copy of this office's Notice of Privacy

Practices.

Please Print Name

Signature

Date

FOR OFFICE USE ONLY We attempted to obtain w r i t t e n acknowledgement of receipt of our Notice or Privacy Practices, but acknowledgement could not be obtained because:

I n d i v i d u a l r e f u s e d to s ign

Communications barriers prohib i ted obtaining the acknowledgement

A n emergency situation prevented us f rom obtaining acknowledgement

Other (Please specify)

R O B E R T M. B A G O F F , D.M.D., L L C 405 Northfield Avenue, Suite 202 West Orange, New Jersey 07052

(973) 325-9000 vyww.TheUnDentist.com

(973) 325-3182 Fax

I hereby grant Dr. Bagoff the absolute and irrevocable right and unrestricted permission in respect ol' photographic pictures taken of me or in which 1 may be included with others. The doctor may use, publish, and re-publish the same photogi"ai)hs in whole or i)art, individually, in cUiy and all media now and hereafter, and for any purpose whatsoever, for illustration, promotion, art, editorial, advertising and trade, or any jourpose whatsoever without restriction as to alterarion; and to use my name if the doctor chooses.

I hereby release and discharge the doctor hom any and all claims and demands arising out of or in connection with tlie use of photographs, including limitations any and all claims for libel or invasion of privacy.

I cUTi ol" lull age and have the light to contract in my own name. I have read the foregoing and fully understand the contents diereof. This release shall be binding upon heirs, legal rei)resentiitives, and assigns.

Patient Printed Name:

Patient Signature:

Date:

Witness:

Address:

Please accept this as my authorization to send ray dental records and x-rays to

Robert M. Bagoff, D.M.D., L L C 405 Northfield Avenue, Suite 202 West Orange, New Jersey 07052 (973) 325-9000 (973) 325-3182 Fax theundentist@gmail.com

Thank you.

Patient Signature Date

Patient Name

SNORING I N D I C A T O R

1. SNORING a. ) Do you snore on most nights? (more than 3 times/week)

Yes (2) No (0) b. ) Is your snoring loud? Can it be heard through a door/wall?

Yes (2) No (0) 2. H A V E Y O U E V E R BEEN T O L D THAT YOU STOP B R E A T H I N G OR GASP DURING S L E E P ?

Never (0) Occasionally (3) Frequently (5) 3. WHAT IS VOUR C O L L A R SIZE?

Men: Less than 17 inches (0) Women: Less than 16 inches (0)

more than 17 inches (5) more than 16 inches (5)

4. DO Y O U O C C A S I O N A L L Y F A L L A S L E E P DURING T H E DAY WHEN: a. ) you are busy or active?

Yes (2) No (0) b. ) you are driving or stopped at a light?

Yes (2) No (0) HAVE YOU HAD OR A R E Y O U BEING T R E A T E D FOR HIGH BLOOD PRESSURE?

Y e s ( l ) No(0 ) TOTAL

Score 9 points or more Refer to sle order sleep

p specialist or study

6 - 8 points Gray area, use clinical judgment

5 points or less Low probability of sleep apnea

ROBERT M. BAGOFF, D.M.D., LLC 405 Northfield Avenue, Suite 202 West Orange, New Jersey 07052

(973) 325-9000 www.TheUnDentist.com