Sleep Screening Questionnaire

Name

Date

Date of Birth

Height

Weight

BMI

Collar size / Neck Circumference

Epworth Sleepiness Scale

How likely are you to doze 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

SITUATION

STOP - BANG

Class 0 - No Bruxism / Clenching

Class I - Mild bruxism defined as visual exam showing minor teeth wear or 1-2 bruxism bursts per sleep hour

Class II - Moderate bruxism defined as visual exam showing moderate teeth wear or 3-4 bruxism bursts per sleep hour

Class III - Severe bruxism defined as visual exam showing teeth wear or 5+ bruxism bursts per sleep hour.

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Signature

Date

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