York Dental Sleep Clinic Questionnaire

Full Name *

Date of Birth *

Address *

Town/City *

Postcode *

Email address *

Source of referral *

GP

Specialist

Self

Recommendation

Comprehensive medical history documented? *

Yes

No

If NO - please click on the following link to complete your medical history (opens in a new window)

https://yorkdentalsleepclinic.co.uk/forms

Reason for visit today (main complaint) *

Have you tried any remedies so far? (e.g. Off shelf device, nasal strips, sprays) *

Yes

No

If so which one and did it help?

Have you been diagnosed with Obstructive Sleep Apnoea (OSA) by a doctor? *

Yes

No

Have you had a sleep test? *

Yes

No

If Yes to above, do you have access to the results?

Yes

No

Have you been offered a CPAP Machine? *

Yes

No

If Yes to above, were you able to tolerate it?

Yes

No

LIFESTYLE AND SPECIFIC HEALTH QUESTIONS

Please indicate whether you suffer from any of the conditions below, giving further and details of medication where indicated.

Heart problems: (e.g. Angina, Heart Attack, Stroke) *

Yes

No

High blood pressure: *

Yes

No

Diabetes (Type I or II): *

Yes

No

Under/Overactive Thyroid: *

Yes

No

Indigestion type symptoms or Gastric reflux: *

Yes

No

Please add details of medical conditions and any medications taken:

Snoring or heavy breathing during sleep: *

Yes

No

Stop Breathing/Choking/ Gasping during sleep: *

Yes

No

How many units of alcohol do you consume weekly? *

(examples:1unit: single spirit, 2 units: glass of wine, 3 units: 1 pint of beer/cider, 9 units: a bottle of wine)

Do you smoke? Y/N *

Yes

No

If Yes how many a day?

Do you use E-cigarettes or Vapes? *

Yes

No

How many hours do you sleep each night? *

How do you feel when you wake up? *

Refreshed

Tired

Groggy

With a headache

Feeling hung-over

With a dry mouth

Choose all that apply

Does your concentration wane after a few hours at work after lunch? *

Yes

No

Do you need a quick nap in the middle of the day? *

Yes

No

SLEEP PARTNERS' QUESTIONNAIRE

Please indicate how you rate your quality of sleep (Choose one answer)

Good

Average

Poor

How would you rate the severity of your partner’s snoring? Choose one.

Noisy breathing but no snoring

Mild snoring

Moderate snoring

Loud snoring

Very loud snoring (heard outside room with closed door)

Please indicate your partner’s (patient’s) quality of sleep (Choose one answer)

Good

Average

Poor

Does your partner’s snoring affect your sleep? (Choose one answer)

Never

Sometimes

Frequently

Always

Epworth Sleepiness Scale

Choose the most appropriate number for each situation

0 = no chance of dozing

1 = slight chance of dozing or sleeping

2 = moderate chance of dozing or sleeping

3 = high chance of dozing or sleeping

Sitting and reading *

Watching TV *

Sitting inactive in a public place *

Lying down to rest in the afternoon when circumstances permits. *

Sitting and talking to someone *

Sitting quietly after lunch without alcohol *

In a car, while stopped for a few minutes in traffic. *

Total Score - This is your Epworth score *

STOP-BANG Sleep Apnoea Questionnaire

(Chung F et al Anaesthesiology 2008 and BJA 2012)

STOP

1. Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors)? *

Yes

No

2. Do you often feel TIRED, fatigued, or sleepy during daytime? *

Yes

No

3. Has anyone OBBSERVED you stop breathing during your sleep? *

Yes

No

4. Do you have or are you being treated for high blood PRESSURE ? *

Yes

No

BANG

1. BMI more than 35kg/m2? *

Yes

No

2. AGE over 50 years old? *

Yes

No

3. NECK circumference >16 inches (40cm)? *

Yes

No

4. GENDER: Male? *

Yes

No

TOTAL SCORE
Please leave blank

York Dental Sleep Clinic
Acomb York YO24 4LZ

01904 798315
info@yorkdentalsleepclinic.co.uk

York Dental Sleep Clinic Questionnaire

York Dental Sleep Clinic Questionnaire

LIFESTYLE AND SPECIFIC HEALTH QUESTIONS

SLEEP PARTNERS' QUESTIONNAIRE

Epworth Sleepiness Scale

STOP-BANG Sleep Apnoea Questionnaire

STOP

BANG

York Dental Sleep ClinicAcomb York YO24 4LZ

01904 798315info@yorkdentalsleepclinic.co.uk

York Dental Sleep Clinic Questionnaire

York Dental Sleep Clinic Questionnaire

LIFESTYLE AND SPECIFIC HEALTH QUESTIONS

SLEEP PARTNERS' QUESTIONNAIRE

Epworth Sleepiness Scale

STOP-BANG Sleep Apnoea Questionnaire

STOP

BANG

York Dental Sleep Clinic
Acomb York YO24 4LZ

01904 798315
info@yorkdentalsleepclinic.co.uk