Sleep Disorder Questionnaire

Please Answer the following questions concerning your health:

	Y     N         I have recently gained weight.
	Y     N         I was told I have high blood pressure.
	Y     N         I use high blood pressure medications.
	Y     N         I take anti-depressants.
	Y     N         I use sleep medications.
	Y     N         I use oxygen at night.
	Y     N         I use medications to help me breath.
	Y     N         I have a regular sleep/wake pattern.

The following questions are designed to identify a sleep problem. Chose the most appropriate number for each situation.  A score of 6 or more indicates the possibility of a sleep disorder and should be discussed with your physician or dentist.

Epworth Scale

In contrast to feeling tired, are you likely to doze or fall asleep in the following situations?

0= Never 1= Slight Chance 2= Moderate Chance 3=Regularly

	______ Sitting & Reading?
	______ Watching Television?
	______ Sitting inactive in a public place (i.e. theater)?
	______ Passenger in a car for an hour without a break?
	______ Lying down to rest in the afternoon?
	______ Sitting and talking to someone?
	______ Sitting quietly after lunch without alcohol?
	______ In a car while stopped for a few minutes in traffic?

______ Total Score

1= Rarely or never  2= Some of the time
3= Frequently  4= Most of the time

Sleepiness
	______ I am sleepy during the day even though I slept through the night.
	______ I am tired during the day even though I slept through the night.
	______ I require a nap to remain awake during the evening.
	______ I fall asleep watching TV even though I try to stay awake.
	______ I fall asleep when driving.
	______ I fall asleep or become sleepy during routine situations.

Sleep Apnea / Snoring
	______ I have been told that I snore loudly even when sleeping on my side.
	______ My snoring disturbs other people.
	______ I have been told that I snore only when sleeping on my back.
	______ I am hoarse in the morning when I wake.
	______ I have been told that I "stop breathing" when sleeping.
	______ I wake up "gasping" or "short of breath".
	______ I wake up in the morning with headaches.
	______ I notice swelling or puffiness in my ankles or feet at night.
	______ I sweat at night when asleep, without being hot.
Narcolepsy
	______ When angry or surprised, I feel like I am going to "black out".
	______ I experience vivid, life like scenes when I am very tired.
	______ I awaken and cannot move, feeling like I am paralyzed.
Other Sleep Behavior
	______ I kick or twitch my legs at night prior to falling asleep.
	______ I have aching or "crawling" sensations at night.
	______ I have been told I kick or twitch my legs or arms when asleep.
	______ I have been told that I grind my teeth when sleeping.
	______ I lie awake for half-an-hour or more before I fall back to sleep.
	______ I wake up at night and cannot go back to sleep.
	______ I walk or talk in my sleep.

Scoring Matrix
	Normal	Mild	Moderate	Severe
Sleepiness	8 or less	9-14	15-19	20-24
Apnea/Snoring	12 or less	13-18	19-26	27-36
Narcolepsy	5 or less	6-7	8-9	10-12
Other	10 or less	11-15	16-21	22-28

Clinical Pathway and Treatment Options

Primary Snoring	Oral Device Therapy and Management
Sleepiness: Moderate/Severe	Physician for consultation
Apnea: Mild/Moderate/Severe	Physician for consultation
Narcolepsy: Mild/Moderate/Severe	Physician for consultation
Other: Moderate/Severe	Physician for consultation