Patient Name(Required) Date MM slash DD slash YYYY Do you have morning headaches? Yes No Do you gasp for breath at night? Yes No Do you wake up tired? Yes No How long do you sleep at night? Do you currently wear a CPAP or have you ever? Yes No Have you had a sleep study? Yes No Epworth Sleepiness Scale In contrast to just feeling tired, how likely are you to doze off or fall asleep in the following situations? Use the following scale to choose the most appropriate number for each situation. 0= would never doze1= slight chance of dozing2= moderate chance of dozing3= high chance of dozingSituation:Sitting and reading Watching TV Sitting inactive in a public place (i.e.: theater) As a car passenger for an hour without a break Lying down to rest in the afternoon Sitting and talking to someone In a car, while stopped for a few minutes in traffic Total score: Thornton Snoring Scale Snoring has a significant effect on the quality of life for many people. Snoring can affect the person snoring and those around him/her both physically and emotionally. Use the scale to choose the most appropriate number for each situation. (Go to 4th statement if have no bed partner). 0= never 1= infrequently (1 night per week)2= frequently (2-3 nights per week) 3= most of the time (4+ nights per weekMy snoring affects my relationship with my partner My snoring causes my bed partner to be irritable or tired My snoring requires us to sleep in separate rooms My snoring is loud My snoring affects people when I am sleeping away from home (hotel, camping, etc.) Total score: Weight Height Age Gender Neck Circumference (inches) DOB Do you snore loudly? (Louder than talking or loud enough to be heard through closed doors) Yes No Do you often feel tired, fatigued or sleepy during the daytime? Yes No Has anyone observed you stop breathing during sleep? Yes No Do you have or are you being treated for high blood pressure? Yes No Have you been diagnosed or treated for any of the following conditions:High Blood pressure Yes No Stroke Yes No Heart Disease Yes No Depression Yes No Diabetes Yes No Sleep apnea Yes No Lung disease Yes No Nasal oxygen use Yes No Insomnia Yes No Restless leg syndrome Yes No Narcolepsy Yes No Morning headaches Yes No Sleeping medication Yes No Pain medication Yes No Mood disorders Yes No Impaired cognition Yes No Additional sleep questionsDo you have Breathing stoppages noticed by bed partner or house mate? Yes No Coughing/choking in the middle or the night or morning? Yes No Wake up at night or morning with a sour taste or reflux? Yes No Wake up at night or morning excessively thirsty? Yes No Frequent night time urination? Yes No Excessive movement at night? Yes No Restless leg syndrome (feeling the need to move when sleeping)? Yes No Night Time clenching or grinding teeth? Yes No Tooth tenderness upon waking? Yes No Sleep Walking? Yes No Vivid Dreaming? Yes No Waking up feeling un-rested? Yes No Pushing the snooze button before getting up for the day? Yes No Daytime sleepiness? Yes No Forgetfulness/ Memory problems? Yes No Headaches without coffee/caffeine? Yes No Lying awake for long periods of time before falling asleep Yes No
