Endre Selmeczy DMD

Sleep Apnea Consultation Request

First Name:

Last Name:

Phone:

Email Address:

Age:

Height (Ft and In):

Weight (Pounds):

Neck Size (Inches):

Ever Stopped Breathing During Sleep:

History of Hypertension:

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 Never
1 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:
2.	My snoring causes my partner to be irritable or tired:
3.	My snoring requires us to sleep in separate rooms:
4.	My snoring is loud:
5.	My snoring affects people when I am sleeping away from home:

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 dozing
1 Slight chance of dozing
2 Moderate chance of dozing
3 High chance of dozing

Situation	Chance of Dozing
Sitting and reading
Watching TV
Sitting inactive in a public place (e.g. a theater or a meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic

This business is local to Livermore, CA.

This form is for use by US-based prospects only.