Click on Calendar, type the year 'YYYY' and pick the month & date.
Dental Care & Wellness of Sonoma County

  Last name

  Mid Initial

  First name

Do you have morning headaches? Yes No
Do you wake up tired? Yes No
Do you gasp for breath at night? Yes No
How long do you sleep a night?
Do you currently wear a C-PAP? Yes No
Have you had a sleep study? Yes No

Epworth Sleepiness Scale

In contrast to just feeling tired, how likely are to doze off or fall asleep in the following situations? Use the following scale to choose the most appropriate number for each situation:
0 = Would Never Doze 1 = Slight Chance Of Dozing
2 = Moderate Chance Of Dozing 3 = High Chance Of Dozing
Siting and reading
Watching television
Sitting inactive in a public place (i.e. in theater)
As a car passenger for an hour without a break
Lying down to rest in afternoon
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car, while stopping for a few minutes in traffic


A score of 8 or greater indicates the possibility of a sleep disordered breathing.

Thornton Snoring Scale

Snoring has a significant effect of the qualify of life for many people. Snoring can affect the person snoring and those around him/her both physically and emotionally. Use the following scale to choose the most appropriate number for each situation. (Skip if you don't have a bed partner)
0 = Never 1 = Infrequently (1 night per week)
2 = Frequently (2-3 nights per week) 3 = Most of the time (4 or more per week)
My snoring affects my relationship with my partner
My snoring causes my partner to be irritable or tired
My snoring requires us to sleep in separate rooms
My snoring is loud
My snoring affects people when I'm sleeping away


A score of 5 or greater indicates your snoring may be significantly your quality of life.

(Your digital signature (full name) is as legally binding as a physical signature.)