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Pre-Treatment Sleep Questionnaire
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- Personal Information
33%
Pre-Treatment Sleep Questionnaires
Name
(Required)
First
Last
Phone
(Required)
Email
Gender
(Required)
Male
Female
Other
Date of Birth
(Required)
DD slash MM slash YYYY
Sleep Apnea Quality of Life Questionnaire (SAQLI)
We would like to understand to what extent your sleep apnea and or snoring is having on your daily activities, emotions, social interactions, and about symptoms that may have resulted. Please insert the best (Response #) that reflects your response to each situation described.
How much have you had to push yourself to remain alert during a typical day? (e.g.school, work, childcare, housework)
A very large amount
A large amount
A moderate to large amount
A moderate amount
A small to moderate amount
A small amount
Not at all
How often have you had to use all of your energy to accomplish your most important activity? (e.g. school, work, childcare, housework)
A very large amount
A large amount
A moderate to large amount
A moderate amount
A small to moderate amount
A small amount
Not at all
How much difficulty have you had finding the energy to do other activities? (e.g. exercise, relaxing activities)
A very large amount
A large amount
A moderate to large amount
A moderate amount
A small to moderate amount
A small amount
Not at all
How much difficulty have you had fighting to stay awake?
A very large amount
A large amount
A moderate to large amount
A moderate amount
A small to moderate amount
A small amount
Not at all
How much of a problem has been to be told that your snoring is irritating?
A very large amount
A large amount
A moderate to large amount
A moderate amount
A small to moderate amount
A small amount
Not at all
How much of a problem have frequent conflicts or arguments been?
A very large amount
A large amount
A moderate to large amount
A moderate amount
A small to moderate amount
A small amount
Not at all
How often have you looked for excuses for being tired?
A very large amount
A large amount
A moderate to large amount
A moderate amount
A small to moderate amount
A small amount
Not at all
How often have you not wanted to do things with your family/and or friends?
A very large amount
A large amount
A moderate to large amount
A moderate amount
A small to moderate amount
A small amount
Not at all
How often have you felt depressed, down, or hopeless?
A very large amount
A large amount
A moderate to large amount
A moderate amount
A small to moderate amount
A small amount
Not at all
How often have you been impatient?
A very large amount
A large amount
A moderate to large amount
A moderate amount
A small to moderate amount
A small amount
Not at all
How much of a problem has it been to cope with everyday issues?
A very large amount
A large amount
A moderate to large amount
A moderate amount
A small to moderate amount
A small amount
Not at all
How much of a problem have you had with decreased energy?
A very large amount
A large amount
A moderate to large amount
A moderate amount
A small to moderate amount
A small amount
Not at all
How much of a problem have you had with fatigue?
A very large amount
A large amount
A moderate to large amount
A moderate amount
A small to moderate amount
A small amount
Not at all
How much of a problem have you had waking up feeling unrefreshed?
A very large amount
A large amount
A moderate to large amount
A moderate amount
A small to moderate amount
A small amount
Not at all
Sleepiness Assessment (Epworth Sleepiness Scale)
How likely are you to doze off or fall asleep in the following situations in contrast to just feeling tired? Even if you have not done some of these things recently, try to work out how they would have affected you. Please insert the best (Response #) that reflects your response to each situation described.
Sitting and reading
No chance of dozing
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Watching television
No chance of dozing
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Sitting inactive in a public place (e.g. a theatre or meeting)
No chance of dozing
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
As a passenger in a car for an hour without a break
No chance of dozing
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Lying down to rest in the afternoon when circumstances permit
No chance of dozing
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Sitting and talking to someone
No chance of dozing
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Sitting quietly after lunch without alcohol
No chance of dozing
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
In a car, while stopped for a few minutes in traffic
No chance of dozing
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
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Treatment Options
Oral Appliance Therapy
Snoring and Sleep Apnea
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Snoring
Sleep Apnea
Sleep Assessment​
Forms & Resources
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Expand
Patient Care
Pre-Treatment Sleep Questionnaire
New Patient Form
Insurance Package
