Get the sleep you deserve - Sleep History Questionnaire

Step 1 of 3 - Personal Information

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Sleep History Questionnaire

Name(Required)

First Last

Gender(Required)

Male

Female

Other

Date of Birth(Required)

DD slash MM slash YYYY

Current weight(Required)

Current height(Required)

Sleep Apnea Quality of Life Questionnaire (SAQLI)

How long have you been aware of your snoring?(Required)

Has it caused problems for relatives/friends?(Required)

Have you been told your breathing stops while asleep ?(Required)

Have you been told you move around a lot while asleep?(Required)

What position do you sleep in?(Required)

Side

Back

Stomach

Approximately how many times per night do you wake up?(Required)

Do you have any difficulty falling asleep at night?(Required)

How many hours of sleep per night do you get?(Required)

Do you most often wake up feeling refreshed?(Required)

Do you often wake up with a headache?(Required)

Does a small amount of alcohol give you a headache?(Required)

Do you feel sleep during the day?(Required)

Frequently

Occasionally

Seldom

Never

What other doctors have you seen about snoring or sleep apnea?(Required)

Sleep History Questionnaire 2

Have you ever had a sleep study?(Required)

Do you have difficulty breathing through your nose?(Required)

Have you gained weight recently?(Required)

If Yes, How much?(Required)

Do you know if you have any heart irregularities?(Required)

Do you have high blood pressure?(Required)

Reading(Required)

Do you have any loss of memory?(Required)

Do you feel depressed?(Required)

Do your jaw joints click?(Required)

Hurt?(Required)

Lock?(Required)

Sleep History Questionnaire

Sleep History Questionnaire

Sleep Apnea Quality of Life Questionnaire (SAQLI)

Sleep History Questionnaire 2

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