LDA - Initial Patient Sleep Screening Form v.10

Initial Patient Sleep Screening Form

LANSDOWNE DENTAL ASSOCIATES
Name

First NameLast Name
Section 1: Epworth Sleepiness Scale
Please indicate how likely you are to doze off or fall asleep in the following situations:

(0=never, 1=slight, 2=moderate, 3=high chance of dozing)

Sitting and reading

	0	1	2	3

0 is Never, 3 is Always

Watching television

	0	1	2	3

0 is Never, 3 is Always

Sitting in a public place

	0	1	2	3

0 is Never, 3 is Always

As a passenger in a car for one hour

	0	1	2	3

0 is Never, 3 is Always

Driving a car stopped for a few minutes in traffic

	0	1	2	3

0 is Never, 3 is Always

Sitting & talking to someone

	0	1	2	3

0 is Never, 3 is Always

Sitting down quietly after lunch without alcohol

	0	1	2	3

0 is Never, 3 is Always

Lying down to rest in the afternoon

	0	1	2	3

0 is Never, 3 is Always

Total Score:
Section 2: Patient Evaluation
Please indicate Yes (1) or No (0) for each question:

Neck Circumference: Is it >17" (men) >15" (women)?

	0	1

0 is No, 1 is Yes

Have you gained at least 15lbs in the last 6 months?

	0	1

0 is No, 1 is Yes

Total Score:
Section 3: Subjective Sleep Evaluation
Please indicate Yes (1) or No (0) for each question:

Do you snore?

	0	1

0 is No, 1 is Yes

You, or your spouse, would consider your snoring louder than a person talking

	0	1

0 is No, 1 is Yes

Your snoring occurs almost every night

	0	1

0 is No, 1 is Yes

Your snoring is bothersome to your bed partner

	0	1

0 is No, 1 is Yes

Do you feel that in some way your sleep is not refreshing or restful?

	0	1

0 is No, 1 is Yes

Do you wake up at night or in the mornings with headaches?

	0	1

0 is No, 1 is Yes

Do you experience fatigue during the day and have difficulty staying awake?

	0	1

0 is No, 1 is Yes

Do you have trouble remembering things or paying attention during the day?

	0	1

0 is No, 1 is Yes

Do you have high blood pressure?

	0	1

0 is No, 1 is Yes

Total Score:
Section 4: Prior Diagnosis

Have you previously been diagnosed with sleep apnea?

	0	1

0 is No, 1 is Yes

If yes:
When were you diagnosed? (Approx mo/yr)
Were you put on CPAP Therapy for treatment?
Are you still using your CPAP every night?
Total Score:
Signature

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Initial Patient Sleep Screening Form

Section 1: Epworth Sleepiness Scale

Section 2: Patient Evaluation

Section 3: Subjective Sleep Evaluation

Section 4: Prior Diagnosis