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