Adult Sleep & Breathing Questionnaire

Date

Patient's Name

Patient's Date of Birth

Age

Gender

Male

Female

Have you ever had a sleep test administered?

Yes

When did you have your last sleep test?

Have you been diagnosed with Sleep Apnea?

Yes

Do you currently use a CPAP or Sleep Appliance for Sleep Apnea?

Yes

Are you happy with your CPAP or Sleep Appliance?

Yes

If you are not happy - why?

How often do you get out of bed to use the restroom during the night?

Do you usually wake feeling tired and unrested?

Yes

Do you habitually snore?

Yes

Have you been diagnosed with Hypertension/High Blood Pressure?

Yes

Do you often suffer from waking headaches?

Yes

Do you regularly experience daytime drowsiness or fatigue?

Yes

Do you have blocked nasal passages?

Yes

Has anyone observed you stop breathing during your sleep?

Yes

Do you ever wake up choking or gasping?

Yes

Do you grind your teeth while sleeping?

Yes

Is your neck circumference greater than 40 cm/15.75"?

Yes

Is your Body Mass Index (BMI) more than 35?

Yes

BMI Formula: BMI = (your weight in pounds × 703) / (your height in inches × your height in inches)

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