866-54-Sleep

3303 E. Baseline Rd. # 105A, Gilbert, AZ 85234
Monday/Wednesday: 8:00am-3:00pm | Tuesday/Thursday: 8:00am-5:00pm

Sleep Questionnaire

Do you wonder about how well you really sleep? Dr. Sheldon Sullivan utilizes the Epworth Sleepiness Scale to measure your daytime sleepiness. Please fill out our form to assess your level of daytime sleepiness. We invite you to contact our office at (866) 54-SLEEP if you have any questions, and to schedule a consultation with our caring dentist.

 

Using the rating scale provided, please select the answer that most closely applies to you.

 

Rating Scale:

  • 0 – Would never doze
  • 1 – Slight chance of dozing
  • 2 – Moderate chance of dozing
  • 3 – High chance of dozing

Situation:

Chance of Dozing:

Sitting and reading

Watching TV

Sitting, inactive in a public place (e.g., movie theatre, meeting, etc.)

As a passenger in a car for an hour or more without a break

Lying down to rest in the afternoon when circumstances permit

Sitting and talking to someone

Sitting quietly after lunch (without having consumed alcohol)

In a car, stopped in traffic for a few minutes

Total:

What your results indicate:

0-10; You are within the normal range for daytime sleepiness in adults. You are most likely getting enough sleep at night.
11-16: You are experiencing mild daytime sleepiness and should probably try to get a little more sleep. You may also want to consider meeting with a doctor or participating in a home-based sleep study to determine the cause of your sleepiness.
17 or higher: You are experiencing severe daytime sleepiness. This level of sleepiness is dangerous, and you should consult with a doctor immediately to determine the cause of your sleepiness and create a treatment plan as soon as possible.

 

This scale should NOT be used for personal diagnosis. It is intended to be used as a tool to help you identify the level of your daytime sleepiness. Daytime sleepiness is often a symptom of a sleep disorder. The underlying medical conditions that cause daytime sleepiness are often easy to diagnose and treat.

 

If you scored 11 or higher, we recommend that you contact our office to schedule a consultation with Dr. Sheldon Sullivan.

Other indicators of a sleep disorder include:

 

  • Do you snore loudly (louder than talking or can be heard through closed doors)?
  • Do you often feel tired, fatigued, or sleepy during daytime?
  • Has anyone observed you stop breathing during sleep?
  • Do you have or are you being treated for high blood pressure?
  • Have you ever woken up suddenly with shortness of breath, gasping, or with your heart racing?
  • Have you had weight gain and find it difficult to lose?
  • Do you wake up with headaches?
  • Do you have trouble falling asleep?
  • Do you have trouble staying asleep once you fall asleep?

 

You may want to consider writing down a list of all your symptoms so that you can describe them as clearly as possible. This will aid in your diagnosis. Please contact us today at Progressive Sleep & Wellness by calling (866) 54-SLEEP to learn more about how we help to treat sleep disorders in Gilbert, Arizona, and to set up your appointment!

Contact Us Today!

Fill out my online form.