ENT Sleep & Snoring Intake

Please check Yes or No to all of the statements*

	Yes	No
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?