Sleep Apnea Consultation Request Blank Form (#3) (#5)First NameLast NamephoneEmailAgeheightweightneckEver Stopped Breathing During Sleep: – Select –YesNoDon’t KnowHistory of Hypertension: – Select –YesNoDon’t Know The Thornton Snoring Scale If you snore, it doesn’t only affect you, depriving you of comfortable rest. It also affects others. The Thornton Snoring Scale can help you determine how your snoring may be influencing the people around you. Choose the most appropriate number for each situation. (Go to question #4, if you have no bed partner.) 0 Never1 Infrequently (1 night per week)2 Frequently (2-3 nights per week)3 Most of the time (4 or more nights per week)1: My snoring affects my relationship with my partner:– Select –0 Never1 Infrequently (1 night per week)2 Frequently (2-3 nights per week)3 Most of the time (4 or more nights per week)2: My snoring causes my partner to be irritable or tired:– Select –0 Never1 Infrequently (1 night per week)2 Frequently (2-3 nights per week)3 Most of the time (4 or more nights per week)3. My snoring requires us to sleep in separate rooms:– Select –0 Never1 Infrequently (1 night per week)2 Frequently (2-3 nights per week)3 Most of the time (4 or more nights per week)4. My snoring is loud:– Select –0 Never1 Infrequently (1 night per week)2 Frequently (2-3 nights per week)3 Most of the time (4 or more nights per week) Dozing Scale In “recent” times, not necessarily today: How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation: 0 No chance of dozing1 Slight chance of dozing2 Moderate chance of dozing3 High chance of dozingSitting and reading– Select –0 No chance of dozing1 Slight chance of dozing2 Moderate chance of dozing3 High chance of dozingWatching TV– Select –0 No chance of dozing1 Slight chance of dozing2 Moderate chance of dozing3 High chance of dozingSitting inactive in a public place (e.g. a theater or a meeting) – Select –0 No chance of dozing1 Slight chance of dozing2 Moderate chance of dozing3 High chance of dozingAs a passenger in a car for an hour without a break – Select –0 No chance of dozing1 Slight chance of dozing2 Moderate chance of dozing3 High chance of dozingLying down to rest in the afternoon when circumstances permit – Select –0 No chance of dozing1 Slight chance of dozing2 Moderate chance of dozing3 High chance of dozingSitting and talking to someone– Select –0 No chance of dozing1 Slight chance of dozing2 Moderate chance of dozing3 High chance of dozingSitting quietly after a lunch without alcohol– Select –0 No chance of dozing1 Slight chance of dozing2 Moderate chance of dozing3 High chance of dozingIn a car, while stopped for a few minutes in traffic– Select –0 No chance of dozing1 Slight chance of dozing2 Moderate chance of dozing3 High chance of dozingSubmit Form
