Form: Sleep Screening Questionnaire

Patient Information

Please answer the questions below to help us assess the possibility of a sleep disorder which may be related to your dental and overall health. There is often a correlation between grinding of the teeth, TMJ disorders, breakdown of the teeth and sleep disorders. Sleep apnea may also increase your risk for many different health conditions including heart attack and stroke. If you are here with your child (under 16), please fill out the lower portion marked “For children only” for your child.

Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations (in contrast to just feeling tired)? 0 = I would never doze 2 = I have a moderate chance of dozing 1 = I have a slight chance of dozing 3 = I have a high chance of dozing

Have you ever been diagnosed with:

Impaired cognition (ie: difficulty concentrating or thinking)
Mood disorder/depression
Insomnia
Hypertension (high blood pressure)
Ischemic Heart disease
History of Stroke
Sleep apenean (if yes, did you try a CPAP?)
TMJ problems significant enough to require treatment
Gastric Reflux or Heartburn

Are you aware of, or have you been told:

Snoring on a regular basis
Feeling tired or fatigued on a regular basis
Clenching or grinding your teeth
Having frequent headaches
Your neck size being >17 inches (male) or >16 inches (female)
Anyone in your family having sleep apnea
Stopping breathing when sleeping/awakening with a gasp

For children only (filled out by a parent or guardian)

Are you aware of your child:
Snoring/noisy breathing while sleeping
Grinding his or her teeth
Wetting the bed
Having difficulty breathing
Being treated for ADD or ADHD
Breathing primarily through their mouth
Having frequent nightmares
Having frequent ear aches

Sign Form

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.