Sleep Apnea Questionnaire
*Please fill out form even if you do not feel that it does not apply*
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient name:
D.O.B:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Physician:
Have you ever had a sleep study done?
Yes
No
If so, when?
Do you have someone observing you while you sleep?
Answer to the best of your ability
Rows
Yes
Seldom
Never
Not Sure
Do you snore?
If you do snore, does it awaken your bed partner?
Do you doze off while watching TV, driving, reading or performing daily activities?
Have you or your bed partner observed that you stop
breathing or gasp for breath while sleeping?
Do you ever wake up out of breath or choking?
Are you a restless sleeper?
Do you have joint aches?
Do you have backaches?
Do you have indigestion or acid reflux?
Do you have or have you ever had high blood pressure?
Have you ever had high cholesterol?
Do you have or have you ever had heart problems?
Do you have night sweats?
Do you have headaches?
Yes
No
If so, how often?
Submit
Should be Empty: