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Sleep Questionnaire
Patient Information
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Name
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First
Last
Phone Number
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Email
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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?
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Yes
No
2. Do you ever awaken with a sensation of gasping or choking?
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Yes
No
3. Has anyone ever noticed that you stop breathing during your sleep?
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Yes
No
4. Do you often wake up with a dry mouth?
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Yes
No
5. Do you find your sleep to be non-refreshing?
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Yes
No
6. Do you often feel tired, fatigued, or sleepy during daytime?
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Yes
No
7. Do you ever fall asleep or nod off in situations where you did not intend to?
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Yes
No
8. Do you have (or are being treated for) high blood pressure and/or diabetes?
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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.
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