PATIENT NAME AGE DOB TODAY’S DATE
Using the 0-3 scale provided, please answer how likely you are to doze off or fall asleep in the following situations, if you allowed yourself to do so:
0 = Would Never Doze 1 = Slight Chance of Dozing 2 = Moderate Chance of Dozing 3 = High Chance of Dozing
Activity Score SITTING AND READING WATCHING TV SITTING, INACTIVE IN A PUBLIC PLACE (THEATER, MEETING ETC.) AS A PASSENGER IN A CAR FOR AN HOUR OR MORE WITHOUT A BREAK LYING DOWN TO REST IN THE AFTERNOON WHEN CIRCUMSTANCES PERMIT SITTING AND TALKING TO SOMEONE SITTING QUIETLY AFTER LUNCH WITHOUT ALCHOHOL IN A CAR, WHILE STOPPED FOR A FEW MINUTES IN TRAFFIC TOTAL
Please mark below if you suffer from, or have been told that you have any of the following:
Loud SnoringFrequent Nighttime UrinationDaytime TirednessDiabetesTold you stop breathing during sleepCOPDDepressionObesity/Weight GainThyroid ProblemsAcid Reflux/HeartburnInability to Lose WeightNever Feel RestedCPAP IntoleranceWake Up GaspingHigh Blood PressureLack of EnergyMorning HeadachesDecreased Concentration
For Women Only:
PregnantPostmenopausal
PremenopausalPolycystic Ovary SyndromeHysterectomy
SIGNS & SYMPTOMS OF ORAL/FACIAL PAIN (Please circle all symptoms that apply)
HEADACHESJAW JOINT PAINJAW JOINT NOISE OR CLICKINGLIMITED MOUTH OPENINGEAR CONGESTIONDIZZINESSRINGING IN EARSDIFFICULTY SWALLOWINGLOOSE TEETHCLENCHING OR GRINDING TEETHFACIAL PAINSENSITIVE TEETHCHEWING DIFFICULTIESNECK PAINPOSTURAL PROBLEMSTINGLING IN FINGERTIPSHOT & COLD TOOTH SENSITIVITYNERVOUSNESS OR INSOMNIA