Sleep Disorder Questionnaire Name*FirstLastEmail*Enter EmailConfirm EmailPhone*Please contact me to discuss my responses by*PhoneEmailBest time to contact me: : HHMMAMPMHave you ever worn a Continious Positive Airway Pressure Device (CPAP, BPAP, APAP) while sleeping?*NoYes, as part of a sleep testYes, I tried one but then stopped using itYes, and I continue to wear itHave you had any nasal or throat surgery?*YesNoHave you ever worn an oral airway appliance while sleeping?*YesNoDo you take a sleep aid medication to help you sleep?*YesNoNo, but I have in the pastHow many hours do you sleep at night?*Less than 4 hours4 to 6 hours6 to 8 hoursMore than 8 hoursDo you snore?*I don't knowNoOccasionallyOftenCheck all that apply:*Fatigue during the dayWaking up frequently during the nightWeight gain or weight lossTrouble concentratingDepressionDecreased job performanceDream frequentlyHave nightmares frequentlyBreathing problems (stop breathing, choking, gasping) during sleepNone of the aboveThere is a high correlation between Sleep Breathing Disorders and TMJ/TMD. Please select all (if any) of the below symptoms that you are experiencing:*Back tightness, soreness, or painNumbness, anywhere in/on bodyEar pressure, fullness, or congestionEar ringing or buzzingDizziness or imbalanceSwallowing difficultyHeadaches or migrainesNeck tightness, soreness, or painFacial painTMJ (jaw joint) painPain when eating/chewingJaw muscles stiff, difficult to open or moveJaw joint clicks, popsBite feels unevenTeeth grindingNone of the aboveRate Your Sleep Disorder 0 = no chance of dozing 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing Please indicate from 0 - 3 the chance of dozing in each scenario below. Sitting and reading:*0123Watching TV:*0123Sitting inactive in a public place (e.g a theater or a meeting):*0123As a passenger in a car for an hour without a break:*0123Lying down to rest in the afternoon when circumstances permit:*0123Sitting and talking to someone:*0123Sitting quietly after a lunch without alcohol:*0123In a car, while stopped for a few minutes in traffic:*0123Please add up all of your responses and enter the total below. Total*01234567891011121314151617181920212223241 – 6 - Congratulations, you're getting enough sleep! 7 – 8 - Your score is average 9 and up - Please seek advice from Deldar Dental without delayHow did you hear about us?Friend or familyInternet searchFacebook, Instagram, Twitter, or YouTubeInsurance ProviderOtherDoctor referred meAdditional questions or comments? We will be sure to address it when we follow up:EmailThis field is for validation purposes and should be left unchanged. We will contact you back with recommendations and whether it’s necessary to come in for an appointment or a consultation.