Sleep Screening Questionnaire

Please correct the errors described below.

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


Have you ever been diagnosed with

Are you aware of (or have you been told)

For children only (filled out by parent or guardian) Are you aware of your child:

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