Sleep Apnea Questionnaire
Have you ever been told you occasionally snore?
Has anyone ever witnessed that you stop breathing while sleeping and/or snoring?
Have you ever been diagnosed with sleep apnea?
Have you been diagnosed with any of the following? Please check all that apply:
High Blood Pressure
History of Heart Attack or Stroke
Please rate the chances of you dozing off in the following situations on a scale of 0-4:
0 - No Chance of Dozing
1 - Slight Chance of Dozing
2 - Moderate Chance of Dozing
3 - High Chance of Dozing
Sitting and reading
Sitting inactive in a public place
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting & talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic
Have you ever tried any of the following to help improve your sleep breathing? Please check all that apply:
Should be Empty: