Sleep Apnea Questionnaire

Have you ever been told you occasionally snore?

Yes No

Has anyone ever witnessed that you stop breathing while sleeping and/or snoring?

Yes No

Have you ever been diagnosed with sleep apnea?

Yes No

Have you been diagnosed with any of the following? Please check all that apply:

High Blood Pressure Heart Disease History of Heart Attack or Stroke Mood Disorder Impaired Thinking Insomnia

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

Watching TV

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:

CPAP Weight Loss Nose Strips Side Sleeping Surgical Treatments

Patient Signature

Electronic Signature

Date

Month Day Year