Richard Bowen, DDS www.bowenlegacydental.com
Taryn Gehlert, DDS Tel:614-459-2300
General, Cosmetic & Implant Dentistry 770 Jasonway Ave
  Columbus, OH 43214

SLEEP QUESTIONNAIRE

    • Patient
    • DOB

    • Today's date
    • BMI
    •  
    •  
    • Have you been told you have sleep apnea?
    • YESNO
    •  
    • Have you been told to wear a CPAP or any other device for breathing at night?
    • YESNO
    •  
    • If yes, do you wear it every night for the entire night?
    • YESNO
    •  
    • Do you take medication, supplements, or over-the-counter substances as sleep aids or headache relief?
    • YESNO
    •  
    • Do you feel rested in the morning?
    • YESNO
    • Please check if you have any of the following:
    • Acid RefluxDepressionDiabetes
      HeadachesHeart DiseaseInsomnia
      StrokeUrination at night (nocturia)Tooth grinding
    •  
    •  
    • STOP BANG SCORE:
    • Do you SNORE?
    • YESNO
    • Do you feel TIRED?
    • YESNO
    • Has anyone OBSERVED you stop breathing during sleep?
    • YESNO
    • Do you have or are you being treated for high blood PRESSURE?
    • YESNO
    • Is your BMI > 30?
    • YESNO
    • AGE: Are you > 50 years old?
    • YESNO
    • Is your NECK circumference > 16"?
    • YESNO
    • GENDER: Are you male?
    • YESNO
    • Total Yes Responses
    • 3-4= Moderate Risk for OSA, 5-8= High Risk for OSA
    •  
    •  
    • EPWORTH SLEEPINESS SCALE:
    • Please indicate your chance of dozing off in the following situations using the following:
    • 0 - Would never doze
    • 1 - Slight chance of dozing
    • 2 - Moderate chance of dozing
    • 3 - High chance of dozing
    •  
    •  
    • Sitting and Reading
    • Laying down to rest in afternoon(when able)
    • Watching TV
    • Sitting and talking with someone
    • Sitting, inactive in public
    • Siting quietly after lunch(w/o alcohol)
    • As a passenger in a car for an hour
    • In a car, stopped for a few minutes in traffic
    •  
    • Total
    • 0-6 Normal, 7-14 Mild Sleepiness, 15-17 Moderate Sleepiness, 18+ Severe Sleepiness
    •  
    •  
    • FOR OFFICE USE ONLY:
    • Patient meets the criteria for a comprehensive sleep evaluation and/or diagnostic sleep study.
    • YESNO
 

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