Sleep Apnea Questionnaire

Name


Email Address


1) How long have you been aware of you snoring


2) Has it caused problems for your relatives or friends?
Yes
No

3) Have you ever been told that your breathing stops during sleep?
Yes
No

4) Has your bed partner ever expressed concern over these pauses?
Yes
No

5) Do you move around in your sleep?
Yes
No

6) How many times a night do you wake up?


7) Do you have any difficulty falling asleep at night?
Yes
No

8) How many hours a night do you normally sleep?


9) Do you wake up in the morning feeling refreshed?
Yes
No

10) Do you often wake up with headaches?
Yes
No

11) How many times do you have to urinate during the night?


12) Do your muscles feel stiff or sore in the morning?
Yes
No

13) Do you feel sleepy during the day?
Yes
No

14) Have you noticed any memory problems?
Yes
No

15) Do you feel depressed often?
Yes
No

16) Are you often unexlainably irritable?
Yes
No

17) Do you often feel dangerously sleepy while driving?
Yes
No

18) Do you have difficulty breathing through your nose?
Yes
No

19) Do you sometimeshave difficulty concentrating?
Yes
No

20) Do you sleep alone?
Yes
No

21) Does you snoring improve by changing body position ?
Yes
No

22) When was your last physical examination?


23) Do you have a history of thyriod disease?
Yes
No

24) Do you have high blood pressure?
Yes
No

25) Have you recently gained weight?
Yes
No

26) Present body weight
kg

27) Height


28) Current medcations


29) Do you smoke?
Yes
No

30) Do you drink alcohol?
Yes
No

31) Are you currently under treatment for a medical problem?
Yes
No

32) Have you had an over-night sleep test?
Yes|
No



Bed Partner Questionnaire

Epworth Sleepiness Scale