Irvine Dentists offering Cosmetic & General Dentistry and Sleep Apnea Treatment in Irvine, South Orange County Irvine Dentists :: Dr. Charles Brown, DDS &Dr. Gerald Kushner, DDS

(949) 833-8020

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Sleep Apnea Treatment
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• Oral Sleep Appliances
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Conveniently located
near the Irvine Spectrum

(949) 833-8020

Sleep Questionnaire

Fill out the form below and receive a free no-obligation 15 minute phone consultation with a dental sleep coordinator to discuss treatment options that may be right for you.

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
Watching television	0 1 2 3
Sitting in a public place	0 1 2 3
As a passenger in a car for one hour	0 1 2 3
Driving a car stopped for a few minutes in traffic	0 1 2 3
Sitting and talking to someone	0 1 2 3
Sitting down quietly after lunch without alcohol	0 1 2 3
Lying down to rest in the afternoon	0 1 2 3

Section 2: Patient Evaluation

Fill in the blanks, or select one Yes or No response for each question:

Height: Weight:
Neck Circumference: Is it >17" (Men) or >15" (Women)?	Yes No
Have you gained 15lbs or more in the past 6 months?	Yes No

Section 3: Subjective Sleep Evaluation

Please select Yes or No for each of the following questions:

Do you snore?	Yes No
Do you or your spouse say you snore louder than someone talking?	Yes No
Does your snoring occur almost every night?	Yes No
Is your snoring bothersome to your bed partner?	Yes No
Do you feel in some way your sleep is not refreshing or restful?	Yes No
Do you wake up at night or in the mornings with headaches?	Yes No
Do you experience fatigue during the day and have difficulty staying awake?	Yes No
Do you have trouble remembering things or paying attention during the day?	Yes No
Do you have high blood pressure?	Yes No

Section 4: Prior Diagnosis

Fill in the blanks, or select one Yes or No response for each question:

Have you previously been diagnosed with sleep apnea?	Yes No
If Yes:
When were you diagnosed? (Approx mo/yr)
Were you put on CPAP Therapy for treatment?
Are you using your CPAP mask every night?
Notes: (Please insert any other notes regarding your snoring, sleep patterns or sleep apnea that you feel may be important)

Your Name:
Email Address:
Phone Number:
If you would like a call to discuss treatment options, what is the best time to call?
Please check:	Current Patient Not a Patient