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

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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

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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