Name* First Last Email* Phone*Sleep Screening QuestionnaireDo You Have Morning Headaches?* Yes No Do You Wake Up Tired?* Yes No Do You Gasp For Breath at Night?* Yes No Are You Currently Wearing a C-PAP?* Yes No Have You Had A Sleep Study?* Yes No Epworth Sleeping ScaleIn contrast to just feeling tired, how likely are you to doze off or fall asleep in the following situations? 0 - Would Never Doze 1 - Slight Chance of Dozing 2 - Moderate Chance Of Dozing 3 - High Chance of DozingSitting and Reading*Select...0 - Would Never Doze1 - Slight Chance 0f Dozing2 - Moderate Chance of Dozing3 - High Chance of DozingWatching Television*Select...0 - Would Never Doze1 - Slight Chance 0f Dozing2 - Moderate Chance of Dozing3 - High Chance of DozingSitting inactive in a public place (i.e. in a theater)*Select...0 - Would Never Doze1 - Slight Chance 0f Dozing2 - Moderate Chance of Dozing3 - High Chance of DozingAs a car passenger for an hour without a break*Select...0 - Would Never Doze1 - Slight Chance 0f Dozing2 - Moderate Chance of Dozing3 - High Chance of DozingLying down to rest in the afternoon*Select...0 - Would Never Doze1 - Slight Chance 0f Dozing2 - Moderate Chance of Dozing3 - High Chance of DozingSitting and talking to someone*Select...0 - Would Never Doze1 - Slight Chance 0f Dozing2 - Moderate Chance of Dozing3 - High Chance of DozingSitting quietly after lunch (without alcohol)*Select...0 - Would Never Doze1 - Slight Chance 0f Dozing2 - Moderate Chance of Dozing3 - High Chance of DozingIn a car, while stopping for a few minutes in traffic*Select...0 - Would Never Doze1 - Slight Chance 0f Dozing2 - Moderate Chance of Dozing3 - High Chance of DozingYour Epworth Sleeping Scale Score*A score of 8 or higher indicates the possibility of sleep disordered breathing.Thornton Snoring ScaleSnoring has a significant effect on the quality of life for many people. Snoring can affect the person snoring and those around them both physically and emotionally. My Snoring affects my relationship with my partner*Select...NeverInfrequentlyFrequentlyMost of the timeMy Snoring causes my partner to be irritable and tired*Select...NeverInfrequentlyFrequentlyMost of the timeMy Snoring requires us to sleep in separate rooms*Select...NeverInfrequentlyFrequentlyMost of the timeMy Snoring is loud*Select...NeverInfrequentlyFrequentlyMost of the timeMy Snoring affects people when I am sleeping away from home (hotel, camping, etc.)*Select...NeverInfrequentlyFrequentlyMost of the timeYour Thornton Snoring Scale Total Score*Scoring higher than 4 indicates your snoring may be significantly affecting your quality of life.Scoring more than 4 Zs indicates your snoring may be significantly affecting your quality of life. 0 | Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z 1 | Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z 2 | Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z 3 | Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z 4 | Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z 5 | Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z 6 | Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z 7 | Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z 8 | Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z 9 | Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z10 | Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z11 | Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z12 | Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z13 | Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z14 | Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z 15 | Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z CommentsThis field is for validation purposes and should be left unchanged.
