Invisalign
Implants
Adult Sleep Apnea
Snoring
Cosmetic Dentistry
Online Sleep Survey
Kids in the Klinic
Your Smile
Healthy Smile
Doctors’ Only
Login
Doctors’ Only
Search for:
Bittner Dental Clinic | Mouthwash 365 | Pure Sleep 365
Home
Our Services
About the Doctor
Credentials
About Us
Request an Appointment
Insurance Information
Partners
Reviews
Contact
Home
Our Services
About the Doctor
Credentials
About Us
Request an Appointment
Insurance Information
Partners
Reviews
Contact
Home
Our Services
About the Doctor
Credentials
About Us
Request an Appointment
Insurance Information
Partners
Reviews
Contact
Search for:
Sleep Survey
Dr. Bittner requests that you complete this “Sleep Disorder Assessment Form.” Please complete the following survey. Your answers will help us determine if an underlying sleep limitation may be affecting your overall health.
Share With Friends
Share
Print
Download
or complete the survey below - Hippa Compliant
ANSWER KEY TO THE QUESTIONS BELOW
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
THORNTON SNORING SCALE
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:
PLEASE LIST THE MAIN REASON(S) YOU ARE SEEKING TREATMENT FOR SNORING OR SLEEP APNEA:
SLEEP SURVEY CONT. 2
DO YOU HAVE OTHER COMPLAINTS?
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
Others:
SUBJECTIVE SIGNS AND SYMPTOMS
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)
Doctor Notes:
DENTAL HEALTH SURVEY
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