Sleep Form

    Your Name (required)
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    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) - SELECT ONE RESPONSE FOR EACH QUESTION

    Sitting and reading
    Watching television
    Sitting in a public place
    As a passenger in a car for one hour
    Driving a car stopped for a few minutes in traffic
    Sitting & talking to someone
    Sitting down quietly after lunch without alcohol
    Lying down to rest in the afternoon

    Total Score:

    Section 2: Patient Evaluation

    Fill in the blanks, select yes or no response for each question.

    Is it greater than or equal to 30?
    Neck Circumference:
    Is it > 17" (Men) or >15"(Women)?
    Have you gained at least 15lbs in the past 6 months?

    Total Score:

    Section 3: Subjective Sleep Evaluation

    Please select yes or no response for each question.

    Do you snore?
    You, or your spouse, would consider your snoring louder than a person talking
    Your snoring occurs almost every night
    Your snoring is bother some to your bed partner
    Do you feel that in some way your sleep is not refreshing or restful?
    Do you wake up at night or in the mornings with headaches?
    Do you experience fatigue during the day and have difficulty staying awake?
    Do you have trouble remembering things or paying attention during the day?
    Do you have high blood pressure?

    Total Score:

    Section 4: Prior Diagnosis

    Have you previously been diagnosed with sleep apnea?

    lf 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:

    Notes: (Please insert any notes for the doctor regarding snoring, sleep patterns or sleep apnea that you feel may be appropriate.)

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