Sleep Apnea Questionnaire

Patient Information:

Medical History:

Do you often feel tired during the day, even after a full night’s sleep
Have you been told that you snore loudly or that you stop breathing during sleep?
Do you experience difficulty staying asleep (insomnia)?
Do you wake up with a dry mouth or sore throat?
Do you wake up frequently with shortness of breath or gasping for air?
Do you have high blood pressure or a history of heart disease?
Have you been diagnosed with any of the following?
Do you smoke or use tobacco products?

Sleep Patterns:

On average, how many hours of sleep do you get per night?
Do you take naps during the day?
How often do you experience difficulty falling asleep?

Next Steps:
​​​​​​​Once your form is submitted, our team will review your responses and reach out to you with the next steps. Thank you for providing this information!

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