WILLAMETTE VALLEY PROSTHODONTICS
Sleep Disorder Assessment

This form determines the need for you to have a user friendly sleep test, which will evaluate if you have a sleep disorder. Sleep Disorders negatively affect your well being and especially your cardio-vascular health, but can be effectively treated.

Have you ever been given a CPAP device?
If you have been given any form of CPAP, do you use it nightly?
Are you comfortable with your CPAP and satisfied with its use?

If your answer is NO to any of the above questions, please continue to Part 1.
If the answer is Yes to the above, PLEASE STOP.

 Part 1 

Epworth Sleepiness Scale

How likely are you to doze off while doing the following activities? Please use the following scale:

0 = Never  |  1 = Slight  |  2 = Moderate  |  3 = High

1. Being a passenger in a motor vehicle for an hour or more
2. Sitting and talking to someone
3. Sitting and reading
4. Watching TV
5. Sitting inactive in a public place
6. Lying down to rest in the afternoon
7. Sitting quietly after lunch without alcohol
8. In a car, while stopped for a few minutes in traffic
 Part 2 
1. Have you been told that you snore?
2. Does your family have a history of premature death in sleep?
3. Do you have diabetes?
4. Have you ever been told you have Coronary Artery Disease?
5. Do you have high blood pressure?
6. Have you ever experienced irregular heart rhythms?
 Part 3 
1. Have you ever been diagnosed with sleep apnea?
2. Do you awaken from sleep with chest pain or shortness of breath
3. Has anyone said that you seem to stop breathing while sleeping?
4. Is your neck size larger than 15” (female) or 16.5” (male)?
5. Have you ever had a stroke?
6. Have you ever been told you have Congestive Heart Failure?
7. Do you have or did you ever have atrial fibrillation?

FOR OFFICE USE ONLY