Sleep Screener

Our Sleep Screener takes just 2-3 minutes and is 90% accurate.

First Name

Last Name

Address

Phone

Primary Care Provider

Have you ever been given a CPAP device?

Yes No

If you have been given a CPAP, do you use it nightly

Yes No

Are you comfortable with your CPAP and satisfied with its use?

Yes No

If the answer is "Yes" to all three questions, YOU ARE DONE! If the answer is "No" to any of the above questions, please continue to Part 1.

Part 1 Epworth Sleepiness Scale

How likely are you to doze off during the following activities? Please use the following scale: 0 = NEVER, 1 = SLIGHT, 2 = MODERATE, 3 = HIGH

Being a passenger in a motor vehicle for an hour or more

0 1 2 3

Sitting and talking to someone

0 1 2 3

Sitting and reading

0 1 2 3

Watching TV

0 1 2 3

Sitting inactive in a public place

0 1 2 3

Lying down to rest in the afternoon

0 1 2 3

Sitting quietly after lunch without alcohol

0 1 2 3

In a car while stopped for a few minutes in traffic

0 1 2 3

PART 2

Have you been told that you snore?

Yes No

Does your family have a history of premature death in their sleep?

Yes No

Do you have diabetes?

Yes No

Have you ever been told you have coronary artery disease?

Yes No

Do you have high blood pressure?

Yes No

Have you experienced irregular heart rhythms?

Yes No

PART 3

Have you ever been diagnosed with Sleep Apnea?

Yes No

Do you awake from sleep with chest pain or shortness of breath?

Yes No

Has anyone ever said that you seem to stop breathing while sleeping?

Yes No

Is your neck size larger than 15" (female) or 16.5" (male)

Yes No

Have you ever had a stroke?

Yes No

Have you ever been told you have congestive heart failure?

Yes No

Did you have or did you ever have atrial fibrillation?

Yes No

TO HELP US REACH OUR MISSION OF SCREENING EVERYONE IN THE VALLEY,
PLEASE TAKE THIS TEST AND URGE YOUR FRIENDS AND FAMILY TO DO THE SAME.

WE PLEDGE TO GRADE YOUR SCREENER AND LET YOU KNOW YOUR RISK WITHIN 3 BUSINESS DAYS.

Dr. Turchin is committed to providing excellence in dentistry.

Phone Number & Email

(970) 925-7730

patientcare@andrewturchin.com

Hours

Monday – Friday: 8:30 AM – 5 PM

Address

400 West Main Street, Suite 100,
Aspen, CO 81611

Our Sleep Screener takes just 2-3 minutes and is 90% accurate.

If the answer is "Yes" to all three questions, YOU ARE DONE! If the answer is "No" to any of the above questions, please continue to Part 1.

Part 1 Epworth Sleepiness Scale

How likely are you to doze off during the following activities? Please use the following scale: 0 = NEVER, 1 = SLIGHT, 2 = MODERATE, 3 = HIGH

PART 2

PART 3

TO HELP US REACH OUR MISSION OF SCREENING EVERYONE IN THE VALLEY, PLEASE TAKE THIS TEST AND URGE YOUR FRIENDS AND FAMILY TO DO THE SAME.

TO HELP US REACH OUR MISSION OF SCREENING EVERYONE IN THE VALLEY,
PLEASE TAKE THIS TEST AND URGE YOUR FRIENDS AND FAMILY TO DO THE SAME.