Airway Screening

Do you have morning headaches?*

YES
NO
Unsure

Do you gasp for breath at night*

YES
NO
Unsure

Do you wake up tired?*

YES
NO
Unsure

How long do you sleep at night (hours)?*

Do you currently wear a CPAP or have you ever?*

YES
NO
Unsure

Have you had a sleep study?*

YES
NO
Unsure

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 dose
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

Situation:

Sitting and reading*

Please enter a number from 0 to 3.

Watching TV*

Please enter a number from 0 to 3.

Sitting inactive in a public place (i.e.: theater)*

Please enter a number from 0 to 3.

As a car passenger for an hour without a break*

Please enter a number from 0 to 3.

Lying down to rest in the afternoon*

Please enter a number from 0 to 3.

Sitting and talking to someone*

Please enter a number from 0 to 3.

In a car, while stopped for a few min in traffic*

Please enter a number from 0 to 3.

Total Score

A score of 8 or greater indicates the possibility of sleep disordered breathing.

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 week)

Situation:

My snoring affects my relationship with my partner*

Please enter a number from 0 to 3.

My snoring causes my bed partner to be irritable or tired*

Please enter a number from 0 to 3.

My snoring requires us to sleep in separate rooms*

Please enter a number from 0 to 3.

My snoring is loud*

Please enter a number from 0 to 3.

My snoring affects people when I am sleeping away from home ( hotel, camping, etc.)*

Please enter a number from 0 to 3.

Total Score

A score of 5 or greater indicates your snoring may be significantly affecting your quality of life.

Patient Name*

Date*

Comments

This field is for validation purposes and should be left unchanged.

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