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  • Adult Sleep Questionnaire

    PATIENT NAME AGE
    DOB TODAY’S DATE

    EPWORTH SLEEPINESS SCALE

    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