Sleep Survey

Dr. Bittner requests that you complete this “Sleep Disorder Assessment Form.” Please complete the following survey. Your answers will help us determine if an underlying sleep limitation may be affecting your overall health.

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or complete the survey below - Hippa Compliant

ANSWER KEY TO THE QUESTIONS BELOW

  • 0 = No Chance of Dozing
  • 1 = Slight Chance of Dozing
  • 2 = Moderate Chance of Dozing
  • 3 = High Chance of Dozing
  • Sitting and Reading
  • Sitting inactive in public place (theatre)
  • As a car passenger for an hour without a break
  • In a car while stopped at a traffic light
  • Sitting quietly after lunch without alcohol
  • Sitting and talking to someone
  • Laying down in the afternoon to rest
  • Watching TV

THORNTON SNORING SCALE

  • 0 = Never
  • 1 = 1 Night a Week
  • 2 = 2-3 nights a week
  • 3 = 4+ nights a week
  • My snoring affects my relationship
  • My snoring is loud
  • My snoring affects people when I am sleeping away from home
  • My snoring requires us to sleep in separate rooms
  • My snoring causes my partner to be irritable or tired
  • Sitting quietly after lunch without alcohol
  • Sitting and talking to someone
  • Lying down in the afternoon to rest

PLEASE LIST THE MAIN REASON(S) YOU ARE SEEKING TREATMENT FOR SNORING OR SLEEP APNEA:

SLEEP SURVEY CONT. 2

DO YOU HAVE OTHER COMPLAINTS?

  • Frequent snoring
  • Difficulty maintaining sleep
  • Excessive Daytime Sleepiness (EDS)
  • Choking while sleeping
  • Difficulty falling asleep
  • Feeling unrefreshed in the morning
  • Waking up gasping/choking
  • Memory problems
  • Morning headaches
  • Impotence
  • Neck or facial pain
  • Nasal problems, difficulty breathing through nose
  • I have been told I stop breathing when I sleep
  • Are you irritable or do you have mood swings

SUBJECTIVE SIGNS AND SYMPTOMS

  • Rate your overall energy level
  • Rate your sleep quality
  • Rate the sound of your snoring
  • Do you have a bed partner?
  • Do you sleep in the same room?
  • On average, how many times per night do you wake up?
  • On average, how many hours of sleep do you get per night?
  • How often do you awaken with headaches?

DENTAL HEALTH SURVEY

  • When was your last dental check-up/complete exam?
  • When was your last dental cleaning?
  • How often do you have your teeth cleaned per year?
  • When was your last dental treatment? What was done?
  • Dentist name and contact info.
  • Are you experiencing any oral pain or discomfort now?
  • Do you brush your teeth twice a day or more?
  • Do you use a fluoride toothpaste?
  • Do you rinse with mouthwash every time you brush?
  • Do your gums bleed when you brush or floss?
  • Does food tend to collect between certain teeth?
  • Do any of your teeth feel loose or move?
  • Are any of your teeth sensitive to cold, hot, sweet or pressure?
  • Are you aware of grinding or clenching your teeth?
  • Do you have difficulty chewing?
  • Do you ever experience tired jaw muscles?
  • Do you have clicking, popping or grating noises in your jaw joint?
  • Do you have any pain in or around your jaw joints?
  • Do you experience tension headaches or ringing in your ears?
  • Are you taking antidepressants or other medications that may affect muscle activity or cause dry mouth?
  • Do you experience dry mouth when you wake up or at any other time?
  • Do you have any sores or ulcers in or around your mouth?
  • Do you have persistent bad breath?
  • Do you have any discolored teeth?
  • Do you have any missing teeth?
  • Do you have any implants or removable partials or dentures?
  • Have you had orthodontic treatment?
  • Have you ever had a serious injury to your head or mouth?
  • How would you rate your smile?

  • Name - First
  • Last
  • Email
  • Phone
  • Address
  • City
  • State
    Zip