The Epworth Sleepiness Scale - Quintana Dental Practice
The Epworth Sleepiness Scale
How likely are you to doze off or fall asleep in the following situations?
Choose the most appropriate number for each situation:
0= would never fall asleep
1= slight chance of falling asleep
2= moderate chance of falling asleep
3= high chance of falling asleep
Activity Score
Sitting and reading _____
Watching TV _____
Sitting, inactive in a public place (theater, meeting, ect.) _____
As a passenger in a car for an hour without a break _____
Lying down to rest in the afternoon when circumstances permit _____
Sitting quietly after lunch without alcohol _____
Sitting and talking to someone _____
In a car, while stopped for a few minutes in traffic _____
Total _____
A score of 9 or above indicates you may be having a problem with daytime sleepiness. Below 9 does not necessarily mean that you do not have a problem. See your healthcare professional for advice if you snore, or have been told that you awake gasping for breath, or if you are sleepy during the day.
Name Date
Personal Information
Date_________________
Mr. Dr. Mrs. Ms. Miss
Name_________________________________________________________________________
Last First Middle Initial
Age________ DOB________ Gender: F M SS#______________________
Height _________ Ft. _________In. Weight
Work Ph _____________ Cell Ph______________ Email __________________________
Address ______________________________________________________________________
City/State/Zip _________________________________________________________________
Previous Address _______________________________________________________________
(Only if you have been at you current address for less than 3 years)
Employer Name & Address _______________________________________________________
______________________________________________________________________________
Family Physician Name & Address _________________________________________________
______________________________________________________________________________
Please list any other health care practitioners you have seen in the past 9 months _____________
______________________________________________________________________________
Insurance _____________________________________________________
Member Number _____________Group Number _____________ Plan Number ____________
Referred By __________________________________________________________________
Sleep Screening Questionnaire
This questionnaire has been designed to provide important facts regarding the history of your sleep condition. To assist in determining the source of any problem, please take your time to answer each question as completely and honestly as possible.
What are the primary concerns for which you are seeking treatment?
Please number the complaints with #1 being the most important
____Frequent heaving snoring
____Nighttime choking spells
____Nocturnal (night time) teeth grinding
____Significant daytime drowsiness
____Feeling un-refreshed in the morning
____Jaw pain
____Jaw clicking
________________________________
Patient Signature
____Morning hoarseness
____Facial pain
____Difficulty falling asleep
____Morning headaches
____I have been told that “I stop breathing” when I am asleep
____Gasping when waking up
____Swelling in ankles/feet
__________________________________
Date
Have you ever had an evaluation at a sleep center? Yes No
Sleep Center Name __________________________________________________
Sleep Center Location ________________________________________________
Continuous Positive Airway Pressure
If you have attempted treatment with a CPAP, but could not tolerate it please check all the following that apply to you:
Mask leaks
I was unable to get the mask to fit properly
Discomfort was caused by the straps and headgear
Disturbed or interrupted sleep was caused by the presence of the device
Noise from the device was disturbing my sleep and/or bed partner’s sleep
CPAP restricted movements during sleep
CPAP does not seem to be effective
Pressure on the upper lip causing tooth related problems
A latex allergy
Claustrophobic associations
An unconscious need to remove the CPAP apparatus at night
Other__________________________
Other Therapy Attempts
What other therapies have you tried for breathing disorders? (Weight loss attempts, smoking cessation for at least one month, surgeries, ect.)
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Patient Signature__________________________________ Date________________________
For Office Use Only
The evaluation confirmed a diagnosis of: Mild Moderate Severe (OSA)
The evaluation revealed an RDI of: _________________ and an AHI of: ___________________
Do you snore?
Yes No Don’t know
Your Snoring is?
Slightly louder than your breathing
As loud as talking
Louder than talking
Very loud (can be heard in adjacent rooms)
How often do you snore?
Nearly every day 3-4 times a week
1-2 times a week 1-2 times a month
Never or nearly never
Has your snoning ever bothered other people?
Yes No Don’t know
Has anyone noticed that you quit breathing during your sleep?
Nearly every day 3-4 times a week
1-2 times a week 1-2 times a month
Never or nearly never
How often do you feel tired or fatigued after you sleep?
Nearly every day 3-4 times a week
1-2 times a week 1-2 times a month
Never or nearly never
During your wake time, do you feel tired, fatigued, or not up to par?
Nearly every day 3-4 times a week
1-2 times a week 1-2 times a month
Never or nearly never
Have you ever nodded off or fallen asleep while driving a vehicle?
Yes No
If you answered yes, how often does it occur?
Nearly every day 3-4 times a week
1-2 times a week 1-2 times a month
Never or nearly never
Do you have high blood pressure?
Yes No Don’t know
For Office Use Only
Scoring Questions: Any answer to a question is a positive response.
Scoring categories:
Category 1: is a positive with 2 or more positive responses to questions 2 - 6 ______
Category 2: is a positive with 2 or more positive responses to questions 7 - 9 ______
Category 3: is a positive with 1 response and/or a BMI>30 (Body Mass Index) ______
Final Result:
2 or more possible categories indicates a high likelihood of sleep disordered breathing
Family History
Have any members of your family (blood kin) ever been diagnosed with:
Heart Disease: Yes No
High Blood Pressure: Yes No
Diabetes: Yes No
Have any immediate family members ever been diagnosed or treated for a sleep disorder:
Yes No Don’t know
Social History
Alcohol consumption: How often do you consume alcohol within 2-3 hours of bedtime?
Never Once a week Several days a week Daily Occasionally
Sedative consumption: How often do you take sedatives within 2-3 hours of bedtime?
Never Once a week Several days a week Daily Occasionally
Caffeine consumption: How often do you consume caffeine within in 2-3 hours of bedtime?
Never Once a week Several days a week Daily Occasionally
Do you smoke:
Yes No
If yes, please enter the number of packs per day or any other description of quantity
____________________________________________________________________________________
Do you use chewing tobacco?
Yes No
Important Notice
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. I understand that I am responsible for all fees for treatment regardless of insurance coverage.
Patient Signature _________________________________ Date__________________________
Medical History
Please answer the following questions to the best of your knowledge:
Anemia ------------------------- Yes No
Arteriosclerosis --------------- Yes No
Asthma ------------------------- Yes No
Autoimmune disorder -------- Yes No
Bleeding easily ---------------- Yes No
Chronic sinus problems ------ Yes No
Chronic fatigue ---------------- Yes No
Congestive heart failure ------ Yes No
Current pregnancy ------------ Yes No
Diabetes ------------------------ Yes No
Dizziness ----------------------- Yes No
Emphysema -------------------- Yes No
Epilepsy ------------------------ Yes No
Fibromyalgia ------------------ Yes No
Frequent sore throat ---------- Yes No
Gastro Esophageal Reflux Disease (GERD) --------------- Yes No
Hay fever ----------------------- Yes No
Heart disorder ----------------- Yes No
Heart mummer ---------------- Yes No
Heart pacemaker -------------- Yes No
Heart valve replacement ----- Yes No
Heartburn or sour a taste in your mouth at night -------- Yes No
Hepatitis ---------------------- Yes No
Injury to -------------------- Yes No
Head Neck Teeth
Face Face
Insomnia --------------------- Yes No
Irregular heart beat --------- Yes No
Jaw joint surgery ------------- Yes No
Low blood pressure -------- Yes No
Memory loss ----------------- Yes No
Migraines -------------------- Yes No
Morning dry mouth -------- Yes No
Muscle spasms or cramps ----------------------- Yes No
Needing extra pillows at night to help breathing ----- Yes No
Nighttime sweating -------- Yes No
Osteoarthritis ---------------- Yes No
Osteoporosis ---------------- Yes No
Poor Circulation ------------ Yes No
Prior orthodontic treatment --------------------- Yes No
Recent excess weight gain --------------------------- Yes No
Rheumatic fever ------------ Yes No
Shortness of breath --------- Yes No
Swollen, stiff, or painful joints ------------------------- Yes No
Tonsillectomy -------------- Yes No
High blood pressure ---------- Yes No
Medical History
Please list any medications you are currently taking:
Antacids ----------------- Yes No
Antibiotics --------------- Yes No
Anticoagulants ---------- Yes No
Antidepressants --------- Yes No
Anti-inflammatory drugs (non-steroid) ---- Yes No
Barbiturates -------------- Ye s No
Blood thinners ---------- Yes No
Codeine ------------------ Yes No
Cortisone ---------------- Yes No
Diet pills ----------------- Yes No
Heart Medication --------------- Yes No
High blood pressure medication ----------------------- Yes No
Insulin ---------------------------- Yes No
Muscle relaxants ---------------- Yes No
Nerve pills ----------------------- Yes No
Pain medication ----------------- Yes No
Sleeping pills ------------------- Yes No
Sulfa drugs ---------------------- Yes No
Tranquilizers -------------------- Yes No
Other current medications: ______________________________________________________________
____________________________________________________________________________________
Please list any medications which have caused you an allergic reaction:
Antibiotics ------------ Yes No
Aspirin ----------------- Yes No
Barbiturates ----------- Yes No
Codeine ---------------- Yes No
Iodine ------------------- Yes No
Latex ------------------- Yes No
Local Anesthetics ----- Yes No
Metals --------------------------- Yes No
Penicillin ------------------------ Yes No
Plastic --------------------------- Yes No
Sedatives ------------------------ Yes No
Sleeping pills ------------------- Yes No
Sulfa drugs --------------------- Yes No
Other Allergies: ________________________________________________________________
_____________________________________________________________________________
Do you have any allergies to medication? Yes No
If yes, please list: _____________________________________________________________________________
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