ENT Sleep & Snoring Intake

Please check Yes or No to all of the statements *

Yes

My family complains about my snoring

People refuse to share a bedroom because of my snoring

Experience loud snoring when sleeping on my back

Experience loud snoring when sleeping on my side

Experience loud snoring even when asleep sitting up

I have been told I stop breathing during sleep

I have been told I choke or gasp during sleep

I wake up with a choking or gasping sensation

I wake up with my heart beating faster than usual

Experience nasal congestion, obstruction or discharge at night

Dry mouth upon awakening

Headaches upon awakening

Waking up feeling tired

Feeling exhausted despite sleeping for many hours

Fighting sleepiness during daily activities

Difficulty staying alert when I am required

Decreased concentration

Forgetfulness

Taking more than 30 minutes to fall asleep on most nights

Wake up during night and have hard time falling back asleep

Waking up early and being unable to fall back asleep

Need to use sleep aids or medications

Unable to sleep at all

"Restlessness of Legs" when lying down in bed before sleep

Leg twitches during sleep

Alcohol use before bed

How likely are you to doze off and fall asleep in the following situations? Even if you have not done some of these things recently, try to remember how you have reacted in the past. Check the most appropriate response for each situation.

Situation:

Epworth Sleepiness Scale *

Never Doze (0)

Slight Chance of Dozing (1)

Moderate Chance of Dozing (2)

High Chance of Dozing (3)

Sitting and Reading?

Watching TV?

Sitting inactive in a public place? (i.e.: Theatre, Movie, Meeting)

As a passenger in a car for an hour without a break?

Lying down to rest in the afternoon at home when conditions permit?

Sitting and talking to someone?

Sitting quietly after a lunch without alcohol?

In a car, while stopped in traffic for a few minutes?