Adult Sleep & Breathing Questionnaire
Date
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Month
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Day
Year
Date
Patient's Name:
Patient's Date of Birth:
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Month
-
Day
Year
Date
Age:
Gender:
Male
Female
Have you ever had a sleep test administered?
Yes
No
If yes - when did you have your last sleep test?
Have you been diagnosed with Sleep Apnea?
Yes
No
Do you currently use a CPAP or Sleep Appliance for Sleep Apnea?
Yes
No
Are you happy with your CPAP or Sleep Appliance?
Yes
No
If you are not happy - why?
How often do you get out of bed to use the restroom during the night?
Rows
Yes
No
Do you usually wake feeling tired and unrested?
Do you habitually snore?
Have you been diagnosed with Hypertension/High Blood Pressure?
Do you often suffer from waking headaches?
Do you regularly experience daytime drowsiness or fatigue?
Do you have blocked nasal passages?
Has anyone observed you stop breathing during your sleep?
Do you ever wake up choking or gasping?
Do you grind your teeth while sleeping?
Submit
Should be Empty: