Sleep Questionnaire

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Sleep Questionnaire

Patient Information

* Indicates required field

Name *

First

Last

Phone Number *

Email *

As part of your diagnostic assessment, we're providing a helpful Sleep Questionnaire for you to complete during a patient visit to help identify patients with Obstructive Sleep Apnea.

1. Do you snore loudly or have been told that you snore? *

Yes No

2. Do you ever awaken with a sensation of gasping or choking? *

Yes No

3. Has anyone ever noticed that you stop breathing during your sleep? *

Yes No

4. Do you often wake up with a dry mouth? *

Yes No

5. Do you find your sleep to be non-refreshing? *

Yes No

6. Do you often feel tired, fatigued, or sleepy during daytime? *

Yes No

7. Do you ever fall asleep or nod off in situations where you did not intend to? *

Yes No

8. Do you have (or are being treated for) high blood pressure and/or diabetes? *

Yes No

If you answered YES to 3 or more questions, you're a candidate for a Sleep Test to evaluate the presence of Obstructive Sleep Apnea.

Submit

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