Sleep Questionnaire

Step 1 of 4

Sleep Questionnaire

Do you have any awareness of snoring or have been told that you do?

Have you been told your breathing stops while asleep?

Is there a family history of snoring / sleep apnea?

Are you a restless sleeper / move around a lot while sleeping?

About how many times per night do you wake up?

Do you most often wake up feeling refreshed?

Do you often wake up with a headache? If applicable, how often per week?

Do your jaw joints click, hurt, lock?

Are you aware of clenching or grinding your teeth? If applicable, when does it occur (at night, during the day)?

Do you have a history of wearing a night guard? If applicable, what is your tolerance of it?

Do you feel sleepy during the day?

Do you have difficulty breathing through your nose?

Do you have a history of acid reflux?

Do you have a history of high blood pressure? If so, what is the reading?

Do you know if you have any heart irregularities?

Do you have any loss of memory, depression / anxiety, moodiness?

Present Weight

Present Height

Have you had a previous sleep test? If so, when?

Current Medications

STOP - Bang Questionnaire

Is it possible that you have Obstructive Sleep Apnea (OSA)?

Please answer the following questions below to determine if you might be at risk.
Snoring?
Do you Snore Loudly (loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night)?

Yes

No
Tired?
Do you often feel Tired, Fatigued, or Sleepy during the daytime (such as falling asleep during driving or talking to someone)?

Yes

No
Observed?
Has anyone Observed you Stop Breathing or Choking/Gasping during your sleep ?

Yes

No
Pressure?
Do you have or are being treated for High Blood Pressure ?

Yes

No
Body Mass Index more than 35 kg/m2?
Calculate your BMI here

Yes

No
Age older than 50 ?(Required)

Yes

No
Neck size large ? (Measured around Adams apple)(Required)
Is your shirt collar 16 inches / 40cm or larger?

Yes

No
Gender?(Required)

Female

Male

Other

Personal Information
Full Name

Date Of Birth
MM slash DD slash YYYY

Today's Date
MM slash DD slash YYYY

Signature

Sleep Questionnaire

Sleepiness Scale

STOP - Bang Questionnaire

Personal Information