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CO2 Oral Tie Releases
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TMJ Botox
About Us
Sleep Apnea Quiz
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(123) 456 789
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Services
Sleep Appliances
CBCT and Airway Health Screenings
CO2 Oral Tie Releases
Myofunctional Collaborative Space
Soft Palate Tightening with Laser
Airway-Focused Dentistry
TMJ Botox
About Us
Sleep Apnea Quiz
Patient Resources
Contact Us
Services
Sleep Appliances
CBCT and Airway Health Screenings
CO2 Oral Tie Releases
Myofunctional Collaborative Space
Soft Palate Tightening with Laser
Airway-Focused Dentistry
TMJ Botox
About Us
Sleep Apnea Quiz
Patient Resources
Contact Us
Austin Sleep & Airway Health
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Services
Sleep Appliances
CBCT and Airway Health Screenings
CO2 Oral Tie Releases
Myofunctional Collaborative Space
Soft Palate Tightening with Laser
Airway-Focused Dentistry
TMJ Botox
About Us
Sleep Apnea Quiz
Patient Resources
Contact Us
Take A Sleep Apnea Test for Adults
"
*
" indicates required fields
Epworth Sleep Evaluation
In the following situations, how likely are you to doze off or fall asleep, in contrast to just feeling tired? Use the following scale to choose the most appropriate number for each situation: Epworth Scoring: 0 = no chance of dozing 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing
Sitting and reading
0
1
2
3
Watching TV
0
1
2
3
Sitting inactive in a public place
0
1
2
3
Being a passenger in a car for an hour
0
1
2
3
Lying down in the afternoon
0
1
2
3
Sitting and talking to someone
0
1
2
3
Sitting quietly after lunch (no alcohol)
0
1
2
3
Stopping for a few minutes in traffic while driving
0
1
2
3
Add up your total from the evaluation above: (Enter the number here)
*
Do you or your child have any of the following symptoms? (check all that apply)
*
Waking up feeling unrefreshed and tired
Often experience morning headaches
You identify that you choke, gasp or stop breathing during sleep
Name
*
First
Last
Email
*
Phone
*
City
*
State
*
"
*
" indicates required fields
Epworth Sleep Evaluation
In the following situations, how likely are you to doze off or fall asleep, in contrast to just feeling tired? Use the following scale to choose the most appropriate number for each situation: Epworth Scoring: 0 = no chance of dozing 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing
Sitting and reading
0
1
2
3
Watching TV
0
1
2
3
Sitting inactive in a public place
0
1
2
3
Being a passenger in a car for an hour
0
1
2
3
Lying down in the afternoon
0
1
2
3
Sitting and talking to someone
0
1
2
3
Sitting quietly after lunch (no alcohol)
0
1
2
3
Stopping for a few minutes in traffic while driving
0
1
2
3
Add up your total from the evaluation above: (Enter the number here)
*
Do you or your child have any of the following symptoms? (check all that apply)
*
Waking up feeling unrefreshed and tired
Often experience morning headaches
You identify that you choke, gasp or stop breathing during sleep
Name
*
First
Last
Email
*
Phone
*
City
*
State
*
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