Dr. Charles R. Verbanic D.D.S

127 Churchill Hubbard Rd, Youngstown, OH, 44505

(330) 759-4550

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 ✱

0 1 2 3

Watching television ✱

0 1 2 3

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

0 1 2 3

As a car passenger for an hour without a break ✱

0 1 2 3

Lying down to rest in the afternoon ✱

0 1 2 3

Sitting and talking to someone ✱

0 1 2 3

Sitting quietly after lunch without alcohol ✱

0 1 2 3

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

0 1 2 3

Epworth Sleepiness Scale Result: You scored:

A score of 8 or greater indicates the possibility of sleep disordered breathing.

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 4th 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)

Fields marked with an ✱ are required

Situation

My snoring affects my relationship with my partner ✱

0 1 2 3

My snoring requires us to sleep in separate rooms ✱

0 1 2 3

My snoring is loud ✱

0 1 2 3

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

0 1 2 3

Thornton Snoring Scale Result: You scored:

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

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

E-Mail

Address

City

State

Zip