SLEEP EVALUATION

Dr. Williamson is joining her peers in the initiative to recognize certain markers for sleep disorders and obstructive airways early before it damages your overall health. We believe that we are in a perfect position to very easily screen for those markers considering the nature of our profession. Dr. Williamson has chosen to incorporate it into every exam just as we screen for oral cancer routinely. Please take a moment and complete the Sleep Evaluation for our records. Obstructive sleep can cause numerous medical conditions, please see below. Please do not hesitate to ask us any questions regarding any of your concerns.

Patient Name:

Date of Birth:		Gender	Male Female	Height:
Weight:		Blood Pressure:		Pulse:

Please check any of the following you may have or have already been diagnosed with:

Diabetes	Heat Disease	Stroke	Insomnia
Frequent Urination at Night	Heat Failure	Depression	Overweight
Erectile Dysfunction	Morning Headaches	ADHD	Hypertension
Atrial Fibrillation	Renal Failure	Chronic Pain	GERD
Night Sweats	Clinch/Grind your teeth	Heart Attack	Chest Pains
Joint Aches	Backaches	Fibromyalgia	Carpal Tunnel Syndrome
Asthma	Allergy Issues

Have you ever been diagnosed with Sleep Apnea?	YES	NO
Are you currently using a CPAP (or any other snoring device)?	YES	NO
Has a physician recommended a sleep study in the past?	YES	NO
Are you currently taking any sleeping aids (prescription or OTC)?	YES	NO
Are you currently taking any prescribed narcotic medication ?	YES	NO
Do you snore or have you been told you snore?	YES	NO
Do you often feel tired, fatigues, or sleepy during the daytime?	YES	NO
Has anyone observed you stop breathing or gasp for air during sleep?	YES	NO
Are you being treated for high blood pressure or have you in the past?	YES	NO

If you answered YES to FOUR or more of the above questions, please continue below:

Epworth Sleepiness Scale	Would Never Doze 0	Slight Chance of Dozing 1	Moderate Chance of Dozing 2	High Chance of Dozing 3
Do you get sleepy, or doze off, while sitting and reading?
Do you get sleepy, or doze off, while watching TV?
While sitting or inactive in public place?
As a passenger in a car for an hour without a break?
Lying down to rest in the afternoon?
Sitting and talking to someone?
Sitting quietly after lunch without alcohol?
In a car, while stopped for a few minutes in traffic?

Total Score

Untreated Sleep Disorders are related to many health and financial complications and are not limited to these below:

Diabetes Erectile Dysfunction

Premature death Daytime fatigue

5x the risk of heart attack ADHD

2x the risk of stroke GERD

Weight Gain Decreased job performance

6x the risk of a serious auto accident Restless Leg Syndrome & Periodic Limb Movement

Increased risk of cancer Increased cost of healthcare

Hypertension Chronic/migraine headaches

Depression Post surgical complications or death

Chronic Pain Weakened immune system

SLEEP EVALUATION

Please check any of the following you may have or have already been diagnosed with:

If you answered YES to FOUR or more of the above questions, please continue below:

Epworth Sleepiness Scale

Untreated Sleep Disorders are related to many health and financial complications and are not limited to these below: