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Confidential Information Questionnaire
Dental History
Medical History
Epworth Sleep Scale
Beck Anxiety Inventory
Beck’s Depression Inventory
Medical History Update
Patient Resources
Videos
Services
General & Preventative Dentistry
Dental Exams & Checkups
Professional Teeth Cleanings
Preventative Dentistry
White Fillings
Night Guards & Sports Guards
Splints
Independent Dental Exams
Oral Sedation
Sleep Dentistry
Sleep Apnea and Snoring Appliances
Mandibular Advancement Devices
Children’s Dentistry
Children’s Dentistry
Oral Health Education
Preventative Care for Children
Emergency Dentistry
Invisalign
Restorative Dentistry
Dental Crowns
Dental Bridges
Dental Implants
Root Canals
Tooth Extractions
Wisdom Teeth Extractions
Same-Day Dentistry
CEREC Same Day Crowns
Cosmetic Dentistry
Dental Veneers
Teeth Whitening
Cosmetic Botox
TMJ, TMD, and Orofacial Pain
TMJ/TMD Therapy
Facial Pain Treatment
Atypical Odontalgia Treatment
Therapeutic Botox
Splints & Nightguards
Additional Services
Laser Labial Frenectomy
Cold Sore Treatment
Periodontal Treatments
Referral
Contact
180 9 St NE #100, Calgary, AB T2E 0P4, Canada
(403) 294 1077
Request Appointment
We Accept The Canadian Dental Care Plan (CDCP)
. Schedule Your Appointment Today!
180 9 St NE #100, Calgary, AB T2E 0P4, Canada
info@alpinedentalcare.ca
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About
About Us
Meet Our Team
CDCP Plan
Blog
Gallery
New Patients
New Patient Forms
Confidential Information Questionnaire
Dental History
Medical History
Epworth Sleep Scale
Beck Anxiety Inventory
Beck’s Depression Inventory
Medical History Update
Patient Resources
Videos
Services
General & Preventative Dentistry
Dental Exams & Checkups
Professional Teeth Cleanings
Preventative Dentistry
White Fillings
Night Guards & Sports Guards
Splints
Independent Dental Exams
Oral Sedation
Sleep Dentistry
Sleep Apnea and Snoring Appliances
Mandibular Advancement Devices
Children’s Dentistry
Children’s Dentistry
Oral Health Education
Preventative Care for Children
Emergency Dentistry
Invisalign
Restorative Dentistry
Dental Crowns
Dental Bridges
Dental Implants
Root Canals
Tooth Extractions
Wisdom Teeth Extractions
Same-Day Dentistry
CEREC Same Day Crowns
Cosmetic Dentistry
Dental Veneers
Teeth Whitening
Cosmetic Botox
TMJ, TMD, and Orofacial Pain
TMJ/TMD Therapy
Facial Pain Treatment
Atypical Odontalgia Treatment
Therapeutic Botox
Splints & Nightguards
Additional Services
Laser Labial Frenectomy
Cold Sore Treatment
Periodontal Treatments
Referral
Contact
About
About Us
Meet Our Team
CDCP Plan
Blog
Gallery
New Patients
New Patient Forms
Confidential Information Questionnaire
Dental History
Medical History
Epworth Sleep Scale
Beck Anxiety Inventory
Beck’s Depression Inventory
Medical History Update
Patient Resources
Videos
Services
General & Preventative Dentistry
Dental Exams & Checkups
Professional Teeth Cleanings
Preventative Dentistry
White Fillings
Night Guards & Sports Guards
Splints
Independent Dental Exams
Oral Sedation
Sleep Dentistry
Sleep Apnea and Snoring Appliances
Mandibular Advancement Devices
Children’s Dentistry
Children’s Dentistry
Oral Health Education
Preventative Care for Children
Emergency Dentistry
Invisalign
Restorative Dentistry
Dental Crowns
Dental Bridges
Dental Implants
Root Canals
Tooth Extractions
Wisdom Teeth Extractions
Same-Day Dentistry
CEREC Same Day Crowns
Cosmetic Dentistry
Dental Veneers
Teeth Whitening
Cosmetic Botox
TMJ, TMD, and Orofacial Pain
TMJ/TMD Therapy
Facial Pain Treatment
Atypical Odontalgia Treatment
Therapeutic Botox
Splints & Nightguards
Additional Services
Laser Labial Frenectomy
Cold Sore Treatment
Periodontal Treatments
Referral
Contact
(403) 294-1077
Book Online
Epworth Sleep Scale
Patient's Legal Name:
(Required)
First
Last
Date of Birth:
(Required)
Month
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling tired? This refers to your usual way of life in recent times. Even if you have not done so some of these things recently try to work out how they would have affected you.
Epworth Sleep Scale
Choose the most appropriate response for each situation.
0. Never Would Doze off
1. Slight chance of dozing
2. Moderate chance of dozing
3. High chance of dozing
Sitting and reading
0
1
2
3
Watching TV
0
1
2
3
Sitting inactive in a public place
0
1
2
3
As a passenger in a car for an hour without a break
0
1
2
3
Laying down to rest in the afternoon when circumstances
0
1
2
3
Sitting and talking with someone
0
1
2
3
Sitting quietly after lunch without alcohol
0
1
2
3
In a car, while stopped for a few minutes
0
1
2
3
STOP-BANG Sleep Apnea Questionnaire
SNORE: Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?
No
Yes
TIRED: Do you often feel tired, fatigued, or sleepy during daytime?
No
Yes
OBSERVED: Has anyone observed you stop breathing during your sleep?
No
Yes
PRESSURE: Do you have or are you being treated for high blood pressure
No
Yes
BMI more than 35kg/m2?
No
Yes
Height
inches (in)
centemetres (cm)
Feet
Height in Feet
3
4
5
6
7
8
Inches
Height in Inches
0
1
2
3
4
5
6
7
8
9
10
11
Centimeters
Weight
pounds (lb)
kilograms (kg)
Pounds
Kilograms
Calculate BMI
AGE over 50 years old?
No
Yes
NECK circumference > 16 inches (40cm)?
No
Yes
GENDER: Male?
No
Yes
CATEGORY 1 QUESTIONS
Do you snore?
Yes
No
I don't know
How loud is your snoring?
My snoring is as loud as breathing
My snoring is as loud as talking
My snoring is louder than talking
My snoring is very loud
How frequently do you snore?
Almost every day
3 - 4 times per week
1 - 2 times per week
1 - 2 times per month
Never or almost never
Does your snoring bother other people?
Yes
No
How often have your breathing pauses been noticed?
Almost every day
3 - 4 times per week
1 - 2 times per week
1 - 2 times per month
Never or almost never
CATEGORY 2 QUESTIONS
Are you tired after sleeping?
Almost every day
3 - 4 times per week
1 - 2 times per week
1 - 2 times per month
Never or almost never
Are you tired during wake-time?
Almost every day
3 - 4 times per week
1 - 2 times per week
1 - 2 times per month
Never or almost never
How often do you nod off or fall asleep while driving?
Almost every day
3 - 4 times per week
1 - 2 times per week
1 - 2 times per month
Never or almost never
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