Snoring Pre-Screening Questionnaire - Fiveways Dental Practice

Snoring and Day Time Sleepiness can have a profound impact on your quality of life:

Day Time Sleepiness - Less effectiveness at work and increased risk of accidents at work

Reduced Energy - Leading to poor motivation to exercise and hence weight gain

Relationships - Sleeping in different bedrooms, reduced sex life and higher stress levels

Hypertension - Patients who snore and have obstructive sleep apnoea have an elevated risk of high blood pressure.

Obstructive Sleep Apnoea is a very serious condition in which a person stops breathing whilst asleep, and occurs in conjunction with snoring.

Both Males and Females can suffer!! (From and Listening to!)

Name*

PrefixFirstLastSuffix

Gender*

Address*

Street AddressAddress Line 2CityZip / Postal CodeCountry

Home Phone

Mobile Phone

Email*

The following questions relate to your lifestyle and general health : Please indicate whether you have suffered with any of the conditions below, giving further details where required.

Heart problems (e.g. Angina, Heart Attacks, Strokes)*

Partner's section

If possible, please get your sleeping partner to complete the questions in the next section to further help (OPTIONAL)

Partners Name

Please indicate YOUR quality of sleep

Good
Average
Poor

Please indicate your PARTNER'S (as above) quality of sleep

Good
Average
Poor

How would you rate the severity of your PARTNER'S snoring

Does your partner's snoring ever disturb YOUR sleep

Does your partner ever hold their breath whilst asleep?

Yes
No
Don't Know

End of Partner Section - Thank you

Epworth Sleepiness Scale - To be completed by Patient

How likely are you to doze off or fall asleep in the following situations (in contrast to you just feeling tired). Even if you haven't been in some of the situations recently, try to work out how they would affect you.

Sitting and Reading*

NEVER Doze
SLIGHT chance
MODERATE chance
HIGH chance

Watching TV*

NEVER Doze
SLIGHT chance
MODERATE chance
HIGH chance

Sitting, inactive in a public place (e.g. a theatre or a meeting)*

NEVER Doze
SLIGHT chance
MODERATE chance
HIGH chance

As a passenger in a car for an hour without a break*

NEVER Doze
SLIGHT chance
MODERATE chance
HIGH chance

Lying down to rest in the afternoon when circumstances permit*

NEVER Doze
SLIGHT chance
MODERATE chance
HIGH chance

Sitting and talking to someone*

NEVER Doze
SLIGHT chance
MODERATE chance
HIGH chance

Sitting quietly after lunch without alcohol*

NEVER Doze
SLIGHT chance
MODERATE chance
HIGH chance

In a car, while stopped for a few minutes in traffic*

NEVER Doze
SLIGHT chance
MODERATE chance
HIGH chance

Flemons Adjusted Neck Circumference

Please measure your actual neck size IN CENTIMETRES (not your collar size for clothes)*

Do you suffer from High Blood Pressure?*

Yes
No

Are you a habitual snorer?*

Yes
No

Do you choke or gasp most nights?*

Yes
No

Many thanks

OK, thats all the info gathering done :-) If you send this in to us then we can assess it and we will then be in contact to arrange your visits to fit your snoring appliance. Just some legal stuff for you to read and aknowledge below please :-)

Patient Information - please read and acknowledge below

Snoring results from a partial closure of the airway during sleep, and most commonly occurs in isolation (simple snoring), or less commonly takes place as part of a more serious condition (obstructive sleep apnoea - OSA) which can be potentially life-threatening. This screening questionnaire helps to identify the degree of risk that you may suffer from OSA. To identify the severity of or to exclude OSA an overnight sleep study would be required.

Dental appliances have been shown to play an effective role in the management of patients with snoring and/or OSA. The appliance will not cure the disorder but works by temporarily repositioning the lower jaw forwards. The tongue is moved forwards preventing the soft palate from being pushed backwards, alleviating airway obstruction. In order to be effective and remain so, the appliance must be worn each and every night. If the use of the appliance is discontinued, the symptoms will recur.

There is no guarantee that a Dental Snoring Appliance will be effective in every patient due to individual variation in response. A high standard of oral hygiene is important for a successful outcome as is the care and use of the device as per supplied instructions.

It is important that you return for your assessment after the fitting of your appliance. You will be asked to complete a simple questionnaire designed to assess your response to treatment and gain feedback from your partner.

For patients with OSA, this post-treatment assessment provides valuable information. A follow-up sleep study with your appliance in place overnight is the only sure way to know if breathing disruptions have been eliminated sufficiently for you to continue using the appliance on its own.

After wearing the appliance all night, a variety of sensations may be experienced on awakening. Most patients report either a dry mouth sensation on awakening, or an excessive amount of saliva. These are short-term effects and lessen with time. On awakening, some patients feel that their teeth do not come together properly and/or their jaw joints or muscles at the side of the face feel tender. These symptoms usually only last for a short time. There is a slight risk that persistent long-term use can result in a degree of movement of your teeth, particularly if you do not maintain the health of your gums. In addition, the splint may require replacement as a result of wear or breakage.

Please complete the boxes below to acknowledge your reading and understanding of the above information.

Patient Consent

I have given complete and accurate replies to the questions within this questionnaire and I have read the information above and understand how a Dental Snoring Appliance may help my snoring. I understand that I would need to undergo an overnight sleep study in order to formally diagnose obstructive sleep apnoea

Name*

Date*

Electronic Signature Equivalent*