Sleep Questionnaire

Step 1 of 3

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

Have you ever been told that your breathing stops while asleep?

Is there a family history of sleep apnea?

Do you have difficulty breathing through your nose?

Are you a restless sleeper/move around a lot when you sleep ?

Do you wake up feeling refreshed?

Do you feel sleepy during the day?

Would your response change if you were not caffeinated?

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

Do you currently use a CPAP?

Do you have a history of wearing a night guard?

Tolerance of night guard?

Do you have a history of acid reflux?

Do you have a history of high blood pressure?

If known, please provide your Blood Pressure Reading.

Present Weight

Present Height

Current Medications

STOP - Bang Questionnaire