Adult Health Screening: Obstructive Sleep Apnea

A risk assessment for obstructive sleep apnea has become the new standard of care in denistry. Thank you for completing this health update and screening.

Your Name:

Your Email:

Phone:    

Epworth Sleepiness Scale (ESS)

0 = No Chance of Dozing

1 = Slight Chance of Dozing

2 = Moderate Chance of Dozing

3 = High Chance of Dozing

Score the following 0 to 3:

  • Sitting and Reading
    0123
  • Watching TV
    0123
  • Sitting inactive in a public place (e.g. theater)
    0123
  • As a passenger for 1 hour without a break
    0123
  • Lying down in the afternoon to rest
    0123
  • Sitting and talking to someone
    0123
  • Sitting quietly after lunch without alcohol
    0123
  • In a car while stopped at a traffic light
    0123

SOCOM Risk Scale (RSS)

  • Snoring - Do you snore and does it affect your partner or others?
    YESNO
  • Observed stop breathing in your sleep?
    YESNO
  • High Blood Pressure?
    YESNO
  • Diabetes?
    YESNO
  • Heart Disease?
    YESNO
  • Sleep Medication?
    YESNO
  • Restless Leg Syndrome?
    YESNO
  • Overweight?
    YESNO