Sleep Assessment

Complete the following questionnaire to the best of your abilities by selecting the best answer for each question. Answers to these questions will help us determine how well you rest at night and the likelihood that you might be suffering from a life-threatening condition. The score for each question will be in parentheses after each question. *

	YES	NO
1. Has anyone told you that you stop breathing while asleep? (4)
2. Have you ever been involved in any type of accident because you nodded off or fell asleep? (3)
3. Have you ever nodded off or fallen asleep while driving? (3)
4. Have you woken up suddenly gasping for air, heart racing or with shortness of breath? (3)
5. Do you grind your teeth? (3)
6. Do you snore or has someone ever told you that you snore? (3)
7. Does anyone in your family have a history of snoring or sleep apnea? (3)
8. Do you feel tired or sleepy throughout the day? (2)
9. Does it take you less than 10 minutes to fall asleep? (2)
10. Does it take you more than 20 minutes to fall asleep? (2)
11. Once you fall asleep, do you have trouble staying asleep? (2)
12. Do you find it difficult to manage your weight? (1)
13. Do you suffer from headaches during the morning or during the night? (1)
14. Have you been diagnosed with high blood pressure or take medication for it? (3)
15. Do you suffer from acid reflux? (3)
16. Do you suffer from heart disease or have you had a stroke? (3)
17. Have you been diagnosed with a sleep disorder? (3)
18. Have you stopped using your CPAP device? (3)
19. Are you wearing your CPAP less than 5 times per week? (3)

Total score corresponding to your "YES" answers:

Schedule a free consultation with Dr. Maruko to discuss your results!

Provide your information below, click Submit, and a member of our team will contact you shortly.

Name

First Name Last Name

Phone Number

Area Code Phone Number

Email

example@example.com

Please note: This assessment is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.