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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