Adult Screening

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Adult Sleep and Airway Questionnaire - Required fields are denoted by an asterick (*)

Epworth Sleepiness Scale

Use this Tool to Measure Sleep Deprivation

The Epworth Sleepiness Scale (below) was developed by researchers in Australia and is widely used by sleep professionals around the world to measure sleep deprivation.

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. If you have not done some of these things recently, think about how they have affected you in the past.

Use the following scale to choose the most appropriate number for each situation:

0 = no chance of dozing
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

Situation and Chance of Dozing:

 

Scoring Interpretation:

0-5 = Normal daytime sleepiness
6-10 = Higher normal daytime sleepiness
11-15 = Mild/Moderated daytime sleepiness
16-24 = Severe excessive daytime sleepiness


Fatigue Severity Scale Questionnaire

Instructions: Select the number that best represents your response to each question.
Scoring range: 1 = strongly disagree with the statement, and 7 = strongly agree with the statement

During the past week, I have found that:

 

Compare results with the following scores:

People who do not experience fatigue score about 2.8
People with Lupus score about 4.6
People with Lyme Disease score about 4.8
People with fatigue related to Multiple Sclerosis score about 5.1
People with Chronic Fatigue Syndrome score about 6.1


NOSE Survey

Do you have trouble breathing through your nose? Over the past ONE month, how much of a problem were the following conditions for you?

Use the following scale to choose the most appropriate number for each situation:

0 = Not a problem
1 = Very mild problem
2 = Moderate problem
3 = Fairly bad problem
4= Severe problem

Situation and Severity of Problem:

 

Scoring Interpretation:

5-25 = Mild nasal obstruction
30-50 = Moderate nasal obstruction
55-75 = Severe nasal obstruction
80-100 = Extreme nasal obstruction


STOP-Bang Questionnaire

Please respond Yes or No to the following questions:


General Sleep Questionnaire

Please respond Yes or No to the following questions: