Initial Sleep Screening Form Please complete to the best of your ability First Name:      Last Name:     Email Address:     Telephone:             Section 1: Epworth Sleepiness Scale Please indicate how likely you are to doze off or fall asleep in the following situations: (0=never, 1=slight, 2=moderate, 3=high chance of dozing)         Sitting and reading   Watching television     Sitting in a public place     As a passenger in a car for one hour     Driving a car stopped for a few minutes in traffic     Sitting and talking to someone     Sitting down quietly after lunch without alcohol     Lying down to rest in the afternoon     Total Score:     Section 2: Patient Evaluation Fill in the blanks, check one yes or no response for each question: BMI (See Chart next page): No (0) | Yes (1)     Is it greater than or equal to 30?     Neck Circumference     Is it >17” (Men) or >15”(Women)?     Have you gained at least 15lbs in the past 6 months?     Total Score:             Section 3: Subjective Sleep Evaluation Please circle one yes or no response for each question   No (0) | Yes (1)     Do you snore?     You, or your spouse, would consider your snoring louder than a person talking?     Your snoring occurs almost every night?     Your snoring is bothersome to your bed partner?     Do you feel that in some way your sleep is not refreshing or restful?     Do you wake up at night or in the mornings with headaches?     Do you experience fatigue during the day and have difficulty staying awake?     Do you have trouble remembering things or paying attention during the day?     Do you have high blood pressure?     Total Score:             Section 4: Prior Diagnosis No (0) | Yes (1)     Have you previously been diagnosed with sleep apnea?          If Yes:  When were you diagnosed? (Approx mo/yr)     Were you put on CPAP Therapy for treatment?     Are you still using your CPAP every night?     Total Score:             Notes: (Please insert any notes for the doctor regarding snoring, sleep patterns or sleep apnea that you feel may be appropriate use back of page if necessary.) Notes for the Doctor Submit Form to Southern Boulevard Dental:

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Martin G. Goebbel, D.D.S. John F. Anton, D.D.S.

Mary Whitlow, Office Manager Valerie Van Why, Office Administrator Shawna Trujeque, Office Administrator AnaMaria Goebbel, Office Administrator Jonelle (Kitty) Rivera, R.D.H. Mary Trujillo, R.D.H. Pamela Beck, Treatment Coordinator Mary Dean, Treatment Coordinator Desiree Solis, Treatment Coordinator

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Rio Rancho, NM 87124
Phone: 505.892.8600