Airway / Myology / TMD Assessment
Fatigue Severity Scale (FSS)
Please choose the number between 1 and 7 which you feel best fits the following statements. This refers to your usual way of life within the last week. 1 indicates "strongly disagree" and 7 indicates "strongly agree."
Reflux Symptom lndex
How Do the Following Problems Affect You? 0 = No Problem 5 = Severe Problem
Note: A total score of 10 or less is normal. A total score of 13 or more suggests laryngopharyngeal reflux.
Nasal Obstruction and Symptoms
Scale 0-5, 5 being severe
SLEEP, SNORING AND APNEA HISTORY
Epworth Sleepiness Scale (EPP)
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 affect you.
Use the following scale and choose the most appropriate number for each situation: 0=no chance, 1=slight chance, 2=moderate chance, 3=high chance.
If you have not worn a CPAP device, skip this section!
GENERAL ORAL MYOLOGY QUESTIONS
Habits and Patterns
Please check those that apply
(evaluation of headache disability)
This questionnaire was designed to help you describe and communicate the way you feel and what you cannot do because of headaches.
INSTRUCTIONS : To complete, please circle one answer for each question.
(Never = 6, Rarely = 9, Sometimes = 10, Very often = 11, Always = 13)
Class I: 36-49
Class II: 50-55
Class III: 56-59
Class IV: 60 and more
We suggest to talk to your physician for class II or more.
WHAT ARE THE CHIEF COMPLAINTS FOR WHICH YOU ARE SEEKING TREATMENT?
Please order your chief complaints by number:
#1 being the 1st or most important,
#2 the 2nd important,
#3 the 3rd less important,
#4, #5, #6... etc.
(please list all)
Rate your chief complaints for frequency as follows:
4= Every Day
Rate the intensity of each complaint ordered on a scale from 0-10.
0= No Pain to
10= Most severe pain
To better coordinate your treatment, please list the professionals you have consulted regarding your present symptoms. Please be sure to list your primary physician and family dentist. Please indicate if you want us to send them a report from your visit.