Form

Sleep Health History

Our office screens all patients for signs and symptoms of obstructive sleep apnea based off the guidelines given to us by the ADA. This screening tool helps us know how to best care for your overall dental and sleep health.

First Name

Last Name

Date Of Birth

Associated Comorbidities (please check all that apply)

Epworth Sleepiness Scale

Please rate your likelihood of falling asleep while doing the activities below, with zero being not at all likely and 3 being a high chance of falling asleep during that activity. Please total your score below after answering the questions.

Total your score from the questions above

Patient/Legal Guardian Signature

Date