Detailed Cases Summary Template
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1Applicant's Name:
Detailed Cases Summary Template
Case Number
1
2
3
4
5
Patient's Age
Patient's Date of Birth
Patient's Gender
Pre-Treatment
Date of Initial Visit
Pre Tx PSG Type
(either in-lab or HSAT)
Pre Tx AHI or RDI
Pre Tx SaO
nadir
2
Name of Interpreting
Board-Certified Sleep
Physician
Date of Oral Appliance
Insertion
Oral Appliance Used
Post-Treatment
Post Tx PSG Type
(either in-lab or HSAT)
Post Tx AHI or RDI
Post Tx SaO
nadir
2
Name of Interpreting
Board-Certified Sleep
Physician
Date of Follow-up
Appointment #1
Date of Follow-up
Appointment #2
Date of Follow-up
Appointment #3
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