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SLEEP QUESTIONNAIRE
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PATIENT NAME
*
WEIGHT
HEIGHT
NECK CIRCUMFERENCE
BMI
SNORING
NIGHTLY
WEEKLY
RARELY
NEVER
OBSERVED PAUSES IN BREATHING
NIGHTLY
WEEKLY
RARELY
NEVER
RESTLESS/INTERRUPTED SLEEP
NIGHTLY
WEEKLY
RARELY
NEVER
AWAKEN SHORT OF BREATH, GASPS, OR SNORTS
NIGHTLY
WEEKLY
RARELY
NEVER
AWAKEN COUGHING
NIGHTLY
WEEKLY
RARELY
NEVER
DIFFICULTY FALLING ASLEEP
NIGHTLY
WEEKLY
RARELY
NEVER
LEG/BODY JERKS
NIGHTLY
WEEKLY
RARELY
NEVER
TEETH GRINDING
NIGHTLY
WEEKLY
RARELY
NEVER
VIVID DREAMS
NIGHTLY
WEEKLY
RARELY
NEVER
HEADACHE DURING NIGHT
NIGHTLY
WEEKLY
RARELY
NEVER
HEADACHE DURING EARLY MORNING
NIGHTLY
WEEKLY
RARELY
NEVER
ALCOHOL CONSUMPTION (Including cough/cold medicine)
NIGHTLY
WEEKLY
RARELY
NEVER
NIGHT TIME URINATION
NIGHTLY
WEEKLY
RARELY
NEVER
HEART PALPITATIONS
NIGHTLY
WEEKLY
RARELY
NEVER
HEART PALPITATIONS
NIGHTLY
WEEKLY
RARELY
NEVER
REFRESHED WITH MORNING WAKE UP
Yes
No
DRY MOUTH WITH MORNING WAKE UP
Yes
No
SORE JAW WITH MORNING WAKE UP
Yes
No
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1-800-419-0210
information@apneasimplified.com
Home
About Sleep Apnea
Our Doctor
For Physicians
Apnea Test Order Form
Order Sleep Test
For Patients
STOP BANG
SLEEP QUESTIONNAIRE
EPWORTH SLEEPINESS SCALE QUESTIONNAIRE
Contact Us