Online Forms

At this time you can print this Patient Information Sheet to fill out your medication list and other information ahead of time.

Please visit our PATIENT PORTAL to register and fill out information before your visit. You can also send secure messages to our office using the patient portal. If you have any questions or issues with the portal please give our office a call.

Epworth Sleepiness Questionnaire

In contrast to just feeling tired, how likely are you to doze off or fall asleep in the following situation? Use the scale below to choose the most appropriate number for each situation. Add the scores together for your total score.

Choose the number from the scale below that best describes the snoring in your situation.

0 = Would never doze off or fall asleep
1 = Slight chance of dozing off or falling asleep
2 = Moderate chance of dozing off or falling asleep
3 = High chance of dozing off or falling asleep

Situation:

Sitting and reading.

Your Score

Watching television.

Sitting inactive in a public place (movie theater)

As a passenger in a car for an hour without a break.

Lying down to rest in the afternoon.

Sitting and talking to someone.

In a car while stopped for a few minutes in traffic.

Total:

If you scored 9 or greater, you may have a sleep disorder. Please call Wilmington Office Phone Number (302)-658-0404 to schedule an appointment at our office in WilmingtonDE.