• MYOBRACE® SLEEP QUESTIONNAIRE

    PATIENT USE ONLY
  • Date of Birth*
     - -
    2 digit day, 2 digit month, 4 digit year
  • Gender*

  • Contact Details

  • Format: 0000 000 000.
  • Format: 0000 000 000.

  • Go to Sleep

    4 QUESTIONS
  • Do you have any problems going to bed or falling asleep?*
  • Do you have an irregular bedtime?*
  • Do you have an irregular wake time?*
  • Does your bedtime/wake time differ greatly between weekdays and weekends?*

  • While Sleeping

    12 QUESTIONS
  • Do you often wake up at night after falling asleep?*
  • Do you snore while sleeping?*
  • Do you snore on most nights (more than three nights per week)?*
  • Do you snore for more than half of the night’s sleep duration?*
  • Do you snore loudly?*
  • Do you have heavy, loud breathing habits while sleeping?*
  • Do you have your mouth open while sleeping?*
  • Do you have difficulty breathing at night while sleeping?*
  • Has it been reported that you stop breathing or gasp during sleeping?*
  • Do you have regular nightmares, sleep walk or have any other unusual sleep behaviors?*
  • Do you think you are not getting enough sleep?*
  • Have you ever had a sleep study (PSG or portable take home study)?*

  • While awake

    13 QUESTIONS
  • Do you feel overtired or sleepy during the day?*
  • Do you wake up feeling unrefreshed in the morning?*
  • Do you find it difficult to wake up in the morning?*
  • Do you wake up with headaches in the morning?*
  • Do you take excessive naps during the day?*
  • Do you tend to breathe through the mouth while awake?*
  • Do you have a dry mouth when you wake up in the morning?*

  • Do you occasionally fall asleep during the day...

  • .. when you are busy or active?*
  • ... when you are driving or stopped at a traffic light?*
  • ... when you are sitting and talking to someone?*
  • ... when you are sitting or inactive in a public place?*
  • Have you been previously or currently treated for high blood pressure?*
  • Are you overweight?*

  • REVIEW

  • Almost done

  • I confirm that the information I have provided above is true and accurate to the best of my knowledge. I agree to inform The Myobrace Centre® / The Myosa Centre® of any changes to my medical or dental history. I consent to The Myobrace Centre® / The Myosa Centre® conducting a preliminary dental, orthodontic and/or temporomandibular joint (TMJ) evaluation and understand that this evaluation is not diagnostic and cannot be presented in written form until such a time that diagnostic records have been taken and a second consultation has been attended.

  • Date
     . .
    2 digit day, 2 digit month, 4 digit year
  • Should be Empty: