Sleep Solutions: Three Easy Steps - Initial Evaluation Forms
ADVERTISEMENT
1
2Initial Evaluation: Step 1
D e n t a l C r a f t e r s , I n c .
Significant Other Form
Sleep Solutions:
Questionnaire for Sleep Apnea and/or Snoring
Three Easy Steps
Your Name:
Partners Name:
Today’s Date:
Initial Evaluation Forms
1. How long have you been aware of your partner’s snoring?
(number of years)
2. Has it caused problems for you or friends?
Yes
No
• Initial Patient Evalution Form
3. Have you noticed that your partner’s breathing stops while asleep?
Yes
No
• Epworth Sleepiness Scale
4. Have you noticed your partner move around a lot while asleep?
Yes
No
• Significant Other Form
5. About how many times per night does your partner wake up?
1–4
5–9
10 or more
6. Does your partner have any difficulty falling asleep at night?
Yes
No
Talk with your patients about their sleeping habits.
7. How many hours of sleep per night does your partner get?
(hours of sleep)
If you believe they may be suffering from a sleep
8. Does your partner most often wake up feeling refreshed?
Yes
No
9. Does your partner often wake up with a headache?
Yes
No
disorder, complete the following forms with the
10. Will a small amount of alcohol give your partner a hangover?
Yes
No
help of your patient and their significant other.
11. Does your partner feel sleepy during the day?
Frequently
Occasionally
Seldom
Never
Uncertain
1000 Corporate Drive • PO Box 770
Marshfield, WI 54449
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business