Epworth Sleep Questionnaire

Complete the form below before your visit. If you have questions, please call Fujioka Family Dentistry at 360-696-4439.

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THE AMERICAN DENTAL ASSOCIATION IS NOW ASKING US TO SCREEN ALL OF OUR PATIENTS FOR SLEEP DISORDERED BREATHING. SLEEP DISORDERS ARE OFTEN UNDIAGNOSED AND HAVE POTENTIALLY SERIOUS MEDICAL AND QUALITY OF LIFE CONSEQUENCES. WE TREAT MILD / MODERATE CASES OF SLEEP APNEA HERE IN OUR OFFICE WITH AN ALTERNATIVE TO THE TRADITIONAL SOLE-USE OF A CPAP MACHINE.

Date* required

Name* required

First*Last*

Do you snore on most nights?

Yes No

Do you experience excessive daytime sleepiness?

Yes No

Has it been reported that you stop breathing or gasp when you sleep?

Yes No

Have you ever had a sleep study or been recommended to get one?

Yes No

If yes, please specify date and location of test:

Do you have a CPAP?

Yes No

If yes, do you wear it on a regular basis? Since when?

What is the chance of you falling asleep when sitting and reading?

0 1 2 3

What is the chance of you falling asleep when watching TV?

0 1 2 3

What is the chance of you falling asleep when sitting inactive in a public place (e.g. a theater or a meeting?)

0 1 2 3

What is the chance of you falling asleep as a passenger in a car for an hour?

0 1 2 3

What is the chance of you falling asleep when lying down to rest in the afternoon when circumstances permit?

0 1 2 3

What is the chance of you falling asleep when sitting and talking to someone?

0 1 2 3

What is the chance of you falling asleep when sitting quietly after a lunch without alcohol?

0 1 2 3

What is the chance of you falling asleep when in a car, while stopped for a few minutes in traffic?

0 1 2 3

0 – No chance of dozing
1 – Slight chance of dozing
2 – Moderate chance of dozing
3 – High chance of dozing

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