Sleep Screening Questionnaire

  • Please answer the questionnaires below to help us assess the possibility of a sleep breathing disorder which may be related to your dental and overall health.
  • MM slash DD slash YYYY
  • Stop-Bang Sleep Apnea Questionnaire: (select yes or no for each question)
    Female >16 inches
    Male >17 inches
  • Epworth Sleepiness Scale: (Answer each on a scale of 0-3)

    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
     1 = I have a slight chance of dozing
    2 = I have a moderate chance of dozing
    3 = I have a high chance of dozing

  • Current Medications or Supplements:Medication Allergies: 
  • MM slash DD slash YYYY