Initial Patient Sleep Screening Form Patient Name: *Section 1: Epworth Sleepiness Scale Please indicate how likely you are to doze off or fall asleep in the following situations: (0=never, 1=slight, 2=moderate, 3=high chance of dozing) – TICK ONE RESPONSE FOR EACH QUESTIONSitting and readingFILL ONE RESPONSE Watching televisionFILL ONE RESPONSE Sitting in a public placeFILL ONE RESPONSE As a passenger in a car for one hourFILL ONE RESPONSE Driving a car stopped for a few minutes in trafficFILL ONE RESPONSE Sitting & talking to someoneFILL ONE RESPONSE Sitting down quietly after lunch without alcoholFILL ONE RESPONSE Lying down to rest in the afternoonFILL ONE RESPONSE Total Score:Section 2: Patient Evaluation Fill in the blanks, circle one yes or no response for each questionBMI (See Attached Chart): Is it greater than or equal to 30?Neck Circumference Is it >17” (Men) or >15”(Women)?Have you gained at least 15lbs in the past 6 months?Total Score:Section 3: Subjective Sleep Evaluation Please select zero or one response for each questionDo you snore?You, or your spouse, would consider your snoring louder than a person talking…Your snoring occurs almost every night…Your snoring is bothersome to your bed partner…Do you feel that in some way your sleep is not refreshing or restful?.Do you wake up at night or in the mornings with headaches?.Do you experience fatigue during the day and have difficulty staying awake?.Do you have trouble remembering things or paying attention during the day?.Do you have high blood pressure?.Total Score: (copy)Paragraph TextCommentSubmit
