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Triangle Snoring and Obstructive Sleep Apnoea (OSA) Questionnaire
Please fill in the form below prior to your appointment and press the submit button once you have finished.

Remember:

  • ​All patients can be treated for snoring with a mandibular advancement splint (MAS)
  • Even if obstructive sleep apnoea is suspected, a mandibular advancement splint can be provided to help treat the patient's snoring
  • If your dentist is concerned about obstructive sleep apnoea (OSA), they will refer you to your GP for further assessment

Snoring and daytime sleepiness can have a profound impact on quality of life:

  • ​Daytime sleepiness - less effectiveness at work and increased risk of accidents
  • Reduced energy - poor motivation to exercise and weight gain
  • Relationship issues - sleeping in different bedrooms, reduced sex life and higher stress levels
  • Hypertension - those who snore or suffer from OSA have an elevated risk of high blood pressure

OSA is a serious condition in which a person stops breathing (or suffers extreme low oxygen levels) whilst asleep. It often occurs in conjunction with snoring.

Patient Details
Medical History
The following questions relate to your lifestyle and general health. Please indicate whether you have suffered with any of the below: (If yes, please provide further details in the box provided)please tick
Please indicate whether you drink alcohol or smoke:
Your Main Concerns:
Are you suffering from any of the following?please tick
Previous treatment in relation to sleep disorders:
Have you had any of the following:please tick
Sleeping Partner Questionnaire (Optional, if partner is present):
Please indicate 'your partner's' quality of sleepResults
Please indicate 'your' quality of sleepResults
How would you rate the severity of your partner's snoring? (Tick one box only)please tick
Does your partner's snoring disturb your sleep? (Tick one box only)please tick
Flemons Adjusted Neck Circumference
What is your neck size/circumference in cm? (not collar size)
Do you have Hypertension / High Blood Pressure
Are you a Habitual Snorer?
Do you Choke or Gasp most nights?

Total=[Field175+Field184+Field187+Field186]

Epworth Sleepiness Scale

How likely are you to dose off or fall asleep in the following situations (in contrast to just feeling tired)? Even if you haven't been in some of these situations recently, try to work out how they may affect you. 


Choose the most appropriate number for each situation:

0 - NEVER Doze

1 - SLIGHT Chance

2 - MODERATE Chance

3 - HIGH Chance

Sitting and Reading
Watching TV
Sitting, inactive in a public place (i.e. theatre, meeting)
As a passenger in a car for an hour, without break
Laying to rest in the afternoon, when circumstances permit
Sitting and talking to someone
Sitting quietly after lunch when NO alcohol has been consumed
In a car stationary for a few minutes in traffic

Total (0-24) = [Field216+Field223+Field222+Field221+Field220+Field219+Field218+Field225]​

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