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Dental Professionals  |
Feel free to print this and fill it out before coming in to our office. Might also be a good idea to give a copy to that spouse who snores!
Patient Name: Date of Birth:
EPWORTH SLEEPINESS SCALE
In contrast to just feeling tired, how likely are you to doze off or fall asleep in the following situations? Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number or each situation. 0 = WOULD NEVER DOZE 1 = SLIGHT CHANCE OF DOZING 2 = MODERATE CHANCE OF DOZING 3 = HIGH CHANCE OF DOZING
SITUATION CHANCE OF DOZING Sitting and Reading Watching TV Sitting inactive in a public place (i.e., in a theatre) As a car passenger for an hour without a break Lying down to rest in the afternoon Sitting and talking to someone Sitting quietly after lunch (without alcohol) In a car, while stopping for a few minutes in traffic
TOTAL SCORE = Have you had a sleep study? ________ Do you own a CPAP? ______ If so, do you use it nightly?_______
SIGNATURE: DATE:
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©2000 21st Century Dental
Site designed and maintained by TNT Dental 4301 N. MacArthur, Suite 100 Irving, Texas 75038 - ph. 888-728-0035 fx: 972-255-5693 |
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