Adult Sleep Questionnaire

Adult Sleep Questionnaire

This form helps to screen for sleep apnea in adults to see if a sleep test is needed. If you suspect you have sleep apnea and you wish to be seen by Dr. Liu at the clinic, please click submit and someone will reach out to you to book an appointment.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date

MonthDayYear
Date
Check all that applies to you. If you answered YES to 3 or more, you may be at risk for sleep apnea.

Snoring more than half of the timePartner, friend, or relative has witnessed you pause or stop breathing during sleepRestless sleep (you move around a lot during the night)Loud snoring that wakes up partner or housematesHard to breath when lying on your backFeels better to sleep on your sideWake up multiple times per night to go to the bathroomClenching or grinding your teeth at nightWake up feeling unrefreshed in the morningsJaw pain or tension in the morningsDifficulty breathing through your noseTired during the daytime without stimulants (coffee, nicotine)Morning headachesMemory lossOverweightHard to loose weight even after implementing exercise & a healthy dietHave acid reflux or heart burnFamily history of sleep apneaHistory of or current AnxietyHistory of or current DepressionHistory of or current High blood pressureHistory of or current Heart diseaseHistory of stroke
STOP Bang Questionnaire (Quick risk assessment of Sleep Apnea). Please check all the ones that apply to you that are a YES. If you answered yes to 3-4 questions, you are intermediet risk. If you answered yes to 4-8 questions, you are high risk.

Do you Snore Loudly (loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night)?Do you often feel Tired, Fatigued, or Sleepy during the daytime (such as falling asleep during driving or talking to someone)?Has anyone Observed you Stop Breathing or Choking/Gasping during your sleep ?Do you have or are being treated for High Blood Pressure ?Body Mass Index more than 35 kg/m2?Age older than 50 ?Neck size large ? (Measured around Adams apple)Is your shirt collar 16 inches / 40cm or larger?Gender = Male ?
Any other comments or concerns?
Thank you for taking the time to fill ou this form. If you wish to be seen by Dr. Liu at the clinic, please click submit and someone will reach out to you to schedule an appointment.
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