Sleep Survey

• 0 = No Chance of Dozing
• 1 = Slight Chance of Dozing
• 2 = Moderate Chance of Dozing
• 3 = High Chance of Dozing

• Sitting and Reading
  0 1 2 3
• Sitting inactive in public place (theatre)
  0 1 2 3
• As a car passenger for an hour without a break
  0 1 2 3
• In a car while stopped at a traffic light
  0 1 2 3
• Sitting quietly after lunch without alcohol
  0 1 2 3
• Sitting and talking to someone
  0 1 2 3
• Laying down in the afternoon to rest
  0 1 2 3
• Watching TV
  0 1 2 3

• 0 = Never
• 1 = 1 Night a Week
• 2 = 2-3 nights a week
• 3 = 4+ nights a week

• My snoring affects my relationship
  0 1 2 3
• My snoring is loud
  0 1 2 3
• My snoring affects people when I am sleeping away from home
  0 1 2 3
• My snoring requires us to sleep in separate rooms
  0 1 2 3
• My snoring causes my partner to be irritable or tired
  0 1 2 3
• Sitting quietly after lunch without alcohol
  0 1 2 3
• Sitting and talking to someone
  0 1 2 3
• Lying down in the afternoon to rest
  0 1 2 3
• Total:

SLEEP SURVEY CONT. 2

• Frequent snoring
  Yes No
• Difficulty maintaining sleep
  Yes No
• Excessive Daytime Sleepiness (EDS)
  Yes No
• Choking while sleeping
  Yes No
• Difficulty falling asleep
  Yes No
• Feeling unrefreshed in the morning
  Yes No
• Waking up gasping/choking
  Yes No
• Memory problems
  Yes No
• Morning headaches
  Yes No
• Impotence
  Yes No
• Neck or facial pain
  Yes No

• Nasal problems, difficulty breathing through nose
  Yes No
• I have been told I stop breathing when I sleep
  Yes No
• Are you irritable or do you have mood swings
  Yes No

• Rate your overall energy level
  1 (Low) 2 3 4 5 (High)
• Rate your sleep quality
  1 (Poor) 2 3 4 5 (Good)
• Rate the sound of your snoring
  1 (Quiet) 2 3 4 5 (Loud)
• Do you have a bed partner?
  Yes No
• Do you sleep in the same room?
  Yes No
• On average, how many times per night do you wake up?
• On average, how many hours of sleep do you get per night?
• How often do you awaken with headaches?
  1 (Never) 2 (Rarely) 3 (Sometimes) 4 (Often) 5 (Daily)

• When was your last dental check-up/complete exam?
• When was your last dental cleaning?
• How often do you have your teeth cleaned per year?
• When was your last dental treatment? What was done?
• Dentist name and contact info.

• Are you experiencing any oral pain or discomfort now?
  Yes No
• Do you brush your teeth twice a day or more?
  Yes No
• Do you use a fluoride toothpaste?
  Yes No
• Do you rinse with mouthwash every time you brush?
  Yes No
• Do your gums bleed when you brush or floss?
  Yes No
• Does food tend to collect between certain teeth?
  Yes No
• Do any of your teeth feel loose or move?
  Yes No
• Are any of your teeth sensitive to cold, hot, sweet or pressure?
  Yes No
• Are you aware of grinding or clenching your teeth?
  Yes No
• Do you have difficulty chewing?
  Yes No
• Do you ever experience tired jaw muscles?
  Yes No
• Do you have clicking, popping or grating noises in your jaw joint?
  Yes No
• Do you have any pain in or around your jaw joints?
  Yes No
• Do you experience tension headaches or ringing in your ears?
  Yes No
• Are you taking antidepressants or other medications that may affect muscle activity or cause dry mouth?
  Yes No
• Do you experience dry mouth when you wake up or at any other time?
  Yes No
• Do you have any sores or ulcers in or around your mouth?
  Yes No
• Do you have persistent bad breath?
  Yes No
• Do you have any discolored teeth?
  Yes No
• Do you have any missing teeth?
  Yes No
• Do you have any implants or removable partials or dentures?
  Yes No
• Have you had orthodontic treatment?
  Yes No
• Have you ever had a serious injury to your head or mouth?
  Yes No
• How would you rate your smile?
  1 (One of my best features) 2(My smile is nice and healthy)
  3(Could be healthier) 4(Needs improvement) 5(I don’t smile often)

• Name - First
• Last
• Email
• Phone
• Address
• City
• State
  Zip