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