Airway Management Consultation ReferralPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Patient NamePhone #Reported Patient History Symptoms: (check all that apply)Snoring and/or Stuffy Nose Upon AwakeningSmall Palate Width (<36mm between Max 1st molars)Clenching/Grinding at NightMaxillary or Mandibular ToriScalloped Tongue or Tongue-TieTMD Popping/Clicking/PainNasal/Sinus Problems or Habitual Mouth BreatherInsomnia/Difficulty falling back to sleepEnlarged Tonsils/AdenoidsRegular restroom uses between 2am-4am (2x+ per week)Daytime Drowsiness/SleepinessUnable to Wear or Tolerate CPAPX-Ray History: CBCTX-Ray History: FMX/PanoStatus of Restorative and/or Orthodontic Care:No further restorative care needs to be done at this timeIn progress restorative care (Crowns/Fillings/Implants)Orthodontic care in progress (braces or clear aligners)Needs orthodontic care Phone Above Reported Please note (For the Above Responses)Comments / Other ConsiderationsReferring Dr. SignatureReferring Dr. Phone #Submit
