Sleep Disorder Questionnaire Sleep Disorder Questionnaire Name*FirstLastEmail*Enter EmailConfirm EmailPhone*Please contact me to discuss my responses by:*PhoneEmailAt appointment (only select if appt is scheduled)Best time to contact me:*MorningAfternoonEveningHave you ever worn a Positive Airway Pressure Device (CPAP, BPAP, APAP) while sleeping?*NoYes, as part of a sleep testYes, I tried one but then stopped using itYes, and I continue to wear itHave you had any nasal or throat surgery?*YesNoHave you ever worn an oral airway appliance while sleeping?*YesNoDo you take a sleep aid medication to help you sleep?*NoYesNo, but I have in the pastHow many hours do you sleep at night?*Less than 4 hours4 to 6 hours6 to 8 hoursMore than 8 hoursDo you snore?*I don't knowNoOccasionallyOftenCheck all that apply:*Fatigue during the dayWaking up frequently during the nightWeight gain or weight lossTrouble concentratingDepressionDecreased job performanceDream frequentlyHave nightmares frequentlyBreathing problems (stop breathing, choking, gasping) during sleepNone of the aboveThere is a high correlation between Sleep Breathing Disorders and TMJ/TMD. Please select all (if any) of the below symptoms that you are experiencing:*Back tightness, soreness, or painNumbness, anywhere in/on bodyEar pressure, fullness, or congestionEar Ringing or BuzzingDizziness or imbalanceSwallowing difficultyHeadaches or migrainesNeck tightness, soreness, or painFacial painTMJ (jaw joint) pain or Ear painPain when eating/chewingJaw muscles stiff, difficult to open or moveJaw joint clicks, popsBite feels unevenTeeth grindingNone of the above Epworth Screening Sleep Test 0 = no chance of dozing 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing Please indicate from 0 - 3 the chance of dozing in each scenario below. Sitting and reading:*0123Watching TV:*0123Sitting inactive in a public place (e.g a theater or a meeting):*0123As a passenger in a car for an hour without a break:*0123Lying down to rest in the afternoon when circumstances permit:*0123Sitting and talking to someone:*0123Sitting quietly after a lunch without alcohol:*0123In a car, while stopped for a few minutes in traffic:*0123 Please add up all of your responses and enter the total below. Total:*0123456789101112131415161718192021222324 1 – 6 - Congratulations, you are getting enough sleep! 7 – 8 - Your score is average 9 and up - Seek the advice of GOODHEALTH.dental without delay Anything else you would like to discuss? Questions? We will be sure to address it when we follow up:NameThis field is for validation purposes and should be left unchanged.