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Dental Concerns
Broken Tooth
Dental Emergency (Trauma)
Dental Pain and Discomfort
Gum Disease
Loose Tooth
Missing Teeth
Teeth Grinding
Teeth Misalignment
Teeth Staining or Discolouration
Sleep Apnoea & Snoring
Facial Aesthetic Concerns
Acne
Crepey Skin
Dark Circles
Droopy Eyelids
Excessive Sweating
Fine Lines & Wrinkles
Jowls
Marionette Lines
Thin Lips
Rosacea
Saggy Skin
Locations
Duthie Dental
The Abbey by Duthie Dental
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Duthie Dental
The Abbey
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Facial Aesthetics
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Anti-Sweating Treatment
Anti-Wrinkle Treatment
Lip Fillers
Profhilo
Polynucleotides
HArmonyCa
Alumier Skincare
Dental Treatment
Menu Toggle
Advanced Dental Treatment
Menu Toggle
Dental Implants
Root Canal Treatment
Oral Surgery
Hypnosis for Dental Anxiety
Anti-Snoring Dental Devices
Child & Adult Fixed Braces
Dentures
Dental Bridge
Dental Crown
Dental Filling
Dental Cosmetics
Menu Toggle
Invisalign
Composite Bonding
Smile Makeover
Air Flow Stain Removal
Veneers
Teeth Whitening
Routine Dental Care
Menu Toggle
Dental Exam
Denplan Care
Scale & Polish
Emergency Dentist
All Treatments
Concerns
Menu Toggle
Dental Concerns
Menu Toggle
Broken Tooth
Dental Emergency (Trauma)
Dental Pain and Discomfort
Gum Disease
Loose Tooth
Missing Teeth
Teeth Grinding
Teeth Misalignment
Teeth Staining or Discolouration
Sleep Apnoea & Snoring
Facial Aesthetic Concerns
Menu Toggle
Acne
Crepey Skin
Dark Circles
Droopy Eyelids
Excessive Sweating
Fine Lines & Wrinkles
Jowls
Marionette Lines
Thin Lips
Rosacea
Saggy Skin
Locations
Menu Toggle
Duthie Dental
The Abbey by Duthie Dental
Prices & Plans
Book Now
Duthie Dental
The Abbey
Pre-Consultation Sleep Questionnaire
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9
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Your Details
Name
(Required)
Prefix
Dr.
Miss
Mr.
Mrs.
Ms.
Prof.
Rev.
Title
First
Last
Email
(Required)
Address
(Required)
Street Address
Address Line 2
City
Postcode
Phone
(Required)
Date of Birth
(Required)
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
Month
Month
1
2
3
4
5
6
7
8
9
10
11
12
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
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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
Do you have a regular dentist?
Yes
No
Your Dentist's Details
Your Dental Practice Name
(Required)
Dental Practice Address
(Required)
Street Address
Address Line 2
City
Postcode
Your GP's Details
Your General Medical Practice Name
(Required)
General Medical Practice Address
(Required)
Street Address
Address Line 2
City
Postcode
Pre-Consultation Questions
This is a pre-assessment screening questionnaire. It provides important baseline information which will be treated in strict confidence.
What are your main concerns or that of your sleeping partner?
Snoring
Bruxism / Tooth Grinding
Sleep Apnoea
Temperomandibular Jaw Joint (TMD) pain
Do you snore?
Yes
No
Details About Your Snoring
How loudly do you snore?
Not Very Loudly
Somewhat Loudly
Loudly
Very Loudly
Extremely Loudly
Do you habitually sleep on your back?
Yes
No
Don’t Know
Does your jaw fall open during sleep?
Yes
No
Don’t Know
Do you awake from sleep feeling choked?
Yes
No
Don’t Know
Do you have trouble breathing through your nose at night?
Yes
No
Don’t Know
More About Your Sleep
Do you awake at night to pass water?
Yes
No
On average how often do you awake at night to pass water?
Once
Two or Three Times
Four or More Times
Do you have a dry mouth or throat in the morning?
Yes
No
Do you suffer from headaches in the morning?
Yes
No
What time do you usually go to sleep?
Hours
:
Minutes
AM
PM
AM/PM
What time do you usually wake up?
Hours
:
Minutes
AM
PM
AM/PM
General Health
Do you suffer from tinnitus?
Yes
No
Please provide details
Weight (Mass) in kilograms
Height in metres
BMI
Stop Bang Questionnaire
Do you Snore loudly (louder than talking or loud enough to be heard through closed doors?)
Yes
No
Do you feel Tired, fatigued or sleepy during the day?
Yes
No
Has anyone Observed you stopping breathing during your sleep?
Yes
No
Do you have or have you been treated for high blood Pressure?
Yes
No
What is your average blood pressure (if known)?
Do you have a BMI more than 35?
Yes
No
Are you over 50 years old?
Yes
No
Is your neck circumference > 16 inches/40cm?
Yes
No
Gender
Male
Female
Obstructive Sleep Apnoea Risk
Low risk of Obstructive Sleep Apnoea
High risk of Obstructive Sleep Apnoea
Epworth Sleepiness Scale
How likely are you to doze off or fall asleep in the situations described below, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you haven’t done some of these things recently try to work out how they would have affected you.
Chance of dozing
Sitting & Reading
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Watching TV
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Sitting, inactive in a public place (e.g. a theatre or a meeting)
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
As a passenger in a car for an hour without a break
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Lying down to rest in the afternoon when circumstances permit
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Sitting and talking to someone
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Sitting quietly after a lunch without alcohol
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
In a car, while stopped for a few minutes in the traffic
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Epworth Score
Normal Range
Abnormal Range
Borderline Range
Previous Efforts to Treat Sleep Disorder
Have you tried any of the following?
Conservative regimens (e.g. weight loss, exercise)
Oral Appliance
CPAP (Nasal continuous positive airway pressure)
Other
Please give details
Have you been involved in a sleep study?
Yes
No
When was your sleep study?
DD slash MM slash YYYY
Where was your previous sleep study?
Please give any details of outcomes you can remember
Are you under a hospital consultant?
Yes
No
Consultant Details
Name of Consultant
Hospital
Last Appointment
(Required)
DD slash MM slash YYYY
Do you have a sleep partner?
Yes
No
This is someone who shares a bed or bedroom with you
Sleep Partner Details
It is helpful to ask your sleep partner questions. Please give their details below and we will e-mail a link requesting they complete some questions about your sleep.
Sleep Partner Name
(Required)
First
Last
Sleep Partner Email
(Required)
Thank you
Thank you for completing the pre-consultation questionnaire.
Consent
(Required)
I agree to the privacy policy.
I agree to my data being processed by The Abbey