Sleep-Related Breathing Disorders Questionnaire

Patient Information:

How often do you experience the following? (1 = Rarely, 10 = Constantly)

Loud snoring

Waking up gasping or choking

Feeling tired during the day, even after a full night’s sleep

Difficulty staying asleep (insomnia)

Morning headaches

Difficulty concentrating or memory problems

Irritability or mood swings

Pauses in breathing during sleep (as observed by a partner)

Do you have any of the following risk factors? (Check all that apply)

High blood pressureExcess weightLarge neck circumferenceFamily history of sleep apneaSmoking

Thank you for completing the questionnaire. Our team will contact you to review your results and schedule a consultation.

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