Pre-Questionnaire Snore Appliance

  • Let's Begin!

    Please fill in our pre-consultation form prior to your face to face appointment.

  • Pre-consultation form

    PLEASE ANSWER ALL QUESTIONS HONESTLY

  • Patient Details

    Please answer all questions
  • Format: (000) 000-0000.
  • Is your enquiry urgent?

  • Pre-consultation

    Please answer all questions as fully as you can. This will provide an important baseline record, all of which will be treated in strict confidence.
  • What is your main concern(s) or that of your sleeping partner? You can select multiple options
  • Do you habitually sleep on your back?
  • Does your jaw fall open during sleep?
  • Do you awake from sleep feeling choked?
  • Do you have trouble breathing through your nose at night?
  • Do you awake at night to go to the toilet?
  • If so, how often do you awake to go to the toilet?
  • Do you have a dry mouth or throat in the morning?
  • Do you suffer from headache in the morning?

  • STOP BANG Questionnaire

  • Epworth Sleep Scale

    How likely are you to fall asleep or doze off in the situations below:

  • Use the following scale to choose the most appropriate answer for each situation:

    0 = Would never doze/fall asleep

    1 = Slight chance of dozing/falling asleep

    2 = Moderate chance of dozing/falling asleep

    3 = High chance of dozing/falling asleep

  • Should be Empty: