Name
Phone
Email
Difficulties trying to conceive or maintain pregnancies? YesNo
Do you suffer from endometriosis or PCOS? YesNo
Do you suffer from gut or digestive issues? YesNo
Do you suffer from symptoms such as burning tongue, dry mouth, or unexplained bone or gum loss? YesNo
Have you noticed your gums bleed when you brush or floss your teeth? YesNo
*Please do not submit any Protected Health Information (PHI).
Do you feel moderately tired, most days? YesNo
Do you wake up with a headache in the center of your forehead? YesNo
Do you suffer fom gut or digestive issues? YesNo
Do you suffer from acid reflux, teeth grinding, diabetes, or take two or more blood pressure medications? YesNo
Do you snore? YesNo
If you answered yes to two or more of these questions, you're high risk for having sleep apnea. Book a consult now so we can help you sleep and feel better!
Full Name Date of Birth
Gender MaleFemaleNon-binaryPrefer not to say Email
Check all that apply Bleeding gums / Periodontal symptomsElevated inflammatory markers (e.g., hsCRP)Autoimmune conditions (RA, Lupus, etc.)Fertility concerns or pregnancyCardiac history or stroke riskDiabetes or metabolic issuesGI symptoms or gut dysbiosisCognitive decline / Family history of dementiaAirway concernsSalivary testingOther If Other, please specify
Provider Notes (optional)
Name Practice
Phone Email
