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If you are unsure whether or not Sleep Easy Dental Spa can help you start getting a better night's rest, take a few moments and fill out our brief sleep screening questionnaire. This questionnaire will provide you with scoring information to two of the most commonly used sleep screening scales with an option to submit your results to our team of medical professionals.

Sleep Screening Questionnaire

Epworth Sleepiness Scale

In contrast to just feeling tired, how likely are you to doze off or fall asleep in the following situations?

Use the following scale to choose the most appropriate number for each situation:

0 = Would never doze
1 = Slight chance of dozing
2 = Moderate chance of dozing
3 = High chance of dozing

Fields marked with an * are required

Situation

Sitting and reading *

Watching television *

Sitting inactive in a public place (i.e. theater) *

As a car passenger for an hour without a break *

Lying down to rest in the afternoon *

Sitting and talking to someone *

Sitting quietly after lunch without alcohol *

In a car, while stopping for a few minutes in traffic *

Thornton Snoring Scale

Snoring has a significant effect on the quality of life for many people. Snoring can affect the person snoring and those around him/her, both physically and emotionally. Use the following scale to choose the most appropriate number for each situation. (Go to the 4^th statement if you have no bed partner.)

0 = Never
1 = Infrequently (1 night per week)
2 = Frequently (2-3 nights per week)
3 = Most of the time (4 or more nights per week)

Situation

My snoring affects my relationship with my partner *

My snoring requires us to sleep in separate rooms *

My snoring is loud *

My snoring affects people when I am sleeping away from home (i.e. hotel, camping, etc.) *

Please provide a valid city.

Your Results

Epworth Sleepiness Scale:

A score of 8 or greater indicates the possibility of sleep disordered breathing. You scored: 0

Thornton Snoring Scale:

A score of 5 or greater indicates your snoring may be significantly affecting your quality of life. You scored: 0

Your Information

To have your sleep screening results reviewed by our team of medical professionals and be contacted by Sleep Easy Dental Spa about potential solutions, please submit the following information. If you would not like to submit your results at this time, please click here.

First Name *

Last Name *

Phone *

Email *

Address *

City *

US States *

Zip *

Think you could benefit from a better night's sleep? Complete our Sleep Screening Questionnaire to learn more about your symptoms and to get in contact with our medical staff.

READY FOR A BETTER NIGHT'S SLEEP

SLEEP SCREENING QUESTIONNAIRE

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