If you cannot tolerate CPAP or choose not to use it, please indicate the reason(s) why:
Epworth Sleepiness Scale
How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling 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. Using the following scale, circle 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
I believe the information provided above to be complete and accurate. I authorize the release of a full report of examination findings, diagnosis, treatment programs, etc., to any referring or treating dentist or physician, and I authorize the release of any medical information to insurance companies for legal documentation necessary to process claims.
Use your mouse cursor or the tip of your finger to sign below