Sleep Solutions: Three Easy Steps - Initial Evaluation Forms Page 2
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1
2The Epworth Sleepiness Scale
D e n t a l C r a f t e r s , I n c .
Initial Patient Evaluation Form
(Patient to complete)
Initial Evaluation Questionnaire
How likely are you to doze off or fall asleep in the following situation?
Name:
Date:
Sex:
Male
Female
0
1
2
3
Date of Birth:
Age:
Check one in
would never
slight chance
moderate chance
high chance
Family Physician:
each row
doze
of dozing
of dozing
of dozing
Is there usually a bed partner to observe your sleep?
Yes
No
Sitting and reading
During the last week:
Never
Rarely
Sometimes
Often
1. Have you snored or have you been told that you do?
Watching TV
2. Have you had choking or shortness of breath sensations at night?
Sitting, inactive in
3. Have you woken up during sleep?
a public place (e.g.
4. Have you had morning fatigue or fogginess or woken up feeling unrefreshed?
theater or meeting)
5. Have you woken up with a headache?
As a passenger in
a car for an hour
6. Have you had chronic sleepiness, fatigue or weariness that you can’t explain?
without a break
7. Have you fallen asleep during the day, particularly when not busy?
Lying down to rest in
8. Have you fallen asleep reading or watching television?
the afternoon when
9. Have you fallen asleep during the day against your will?
circumstances permit
10. Have you had to pull off the road while driving due to sleepiness?
Sitting and talking
11. Have you been more irritable and short-tempered?
to someone
12. Have you felt your working habits and/or intellect is impaired?
Sitting quietly
13. Have you been told that you stop breathing while asleep?
after lunch
without alcohol
14. Do you have difficulty breathing through your nose?
15. Have you gained weight recently?
If so, approximately how much?
In a car, while stopped
for a few minutes in
16. Present body weight:
Height:
the traffic
17. What other doctors have you seen about your snoring or sleep apnea?
18. Have you had a sleep lab study?
Yes
No
Date of study?
Total Score:
19. What professional advice or treatment have you received about your snoring or sleep apnea?
(Add columns 0-3)
20. Have you attemted treatment with C.P.A.P. device?
Yes
No
21. Do you use C.P.A.P.?
Yes
No
Patient Signature:
Date:
Patient Signature:
Date:
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