Sleep and Snoring Questionnaire

PLEASE ANSWER LEGIBLY TO THE BEST OF YOUR KNOWLEDGE

Name

Date

Height

Weight

Do you take sleeping pills?

Yes No

If yes, what kind?

Do you take any kind of medicine that affects your sleep?

Yes No

If yes, please list

Do you have any of the following? (Requiring medication or hospitalization)

High blood pressure

Yes No

Irregular heart beat

Yes No

Sleep apnea

Yes No

Heart failure

Yes No

Thyroid disease

Yes No

Heart valve replacement

Yes No

Please mark any of the following surgeries you have had:

Ton sillectomy

Tracheotomy

Nasal surgery

Adenoidectomy

Uvulopalatoplasty (UVP I UVPP)

Sinussurgery

Other oral surgery (list):

Other:

Have you had a sleep study?

Yes No

If yes, where?

Have you had any previous snoring or sleep treatment?

Yes No

If yes, please mark:

CPAP

UPPP

Nasal Surgery

Tonsillectomy

Dental Appliance

Maxillary Surgery

Pillar

Other

Epworth Sleepiness Scale

Name

Date

Age (years)

How likely are you to doze off or fall asleep in the following situations, instead of just feeling tired? This is about your recent and usual way of life.

Even if you have not done some of these thingsrecently, try to think about how they would affect you.

Use the following scale to choose the most appropriate number for each situation:

0 - would never doze or sleep | 1 - slight chance of dozing or sleeping |

2 - moderate chance of dozing or sleeping | 3 - high chance of dozing or sleeping

It is important that you answer each question as best as you can

Sitting and Reading

0 1 2 3

Watching TV

0 1 2 3

Sitting, not active, in a public place (movie theatre or a meeting)

0 1 2 3

Being a passenger in a car for an hour without stopping

0 1 2 3

Lying down in the afternoon

0 1 2 3

Sitting and talking to someone

0 1 2 3

Sitting quietly after a lunch (no alcohol)

0 1 2 3

Stopped for a few minutes in traffic while driving

0 1 2 3

Total:

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