Sleep Survey

Please answer the following questions.                 Sleep Survey in PDF format. Print and bring to office.

Do you snore loudly?________Yes________No
I don't feel refreshed, even after sleeping all night?________Yes________No
Have you been told that you quit breathing during sleep.________Yes________No
I am tired all the time.________Yes________No
Do you take medication for high blood pressure?________Yes________No
Do you have a restless sleep?________Yes________No
Do you get up during the night frequently to go to the bathroom? ________Yes________No
I am sleepy during the day. ________Yes________No
Do you clench or grind your teeth at night? ________Yes________No
Do you wake up in the morning with a headache? ________Yes________No
If you answered yes to any of these question you may be at risk for a sleep related breathing disorder.

The next set of questions is the Epworth Scale. It was designed and used by doctors to help patients distinguish the difference between being sleepy verses being tired. As you read each situation, think of how likely you are to doze off or fall asleep. Even if you have not done some of these things recently, try to determine how they would have affected you.

Use the following scale to score:
0 = would NEVER doze, 1= SLIGHT chance of dozing, 2= MODERATE chance of dozing, 3=HIGH chance of dozing

ADD all numbers for TOTAL SCORE:
Score
a) Sitting and reading
b) Watching TV
c) Sitting, inactive in a public place (e.g., a theatre or a meeting)
d) As a passenger in a car for an hour without a break
e) Lying down to rest in the afternoon when circumstances permit
f) Sitting and talking to someone
g) Sitting quietly after a lunch without alcohol
h) In a car, while stopped for a few minutes in traffic

If your score is higher than 6, there is a chance that you may be at risk for Obstructive Sleep Apnea. Please call the office for an appointment and be screened.