Sleep Apnea Questionnaire

Think you may suffer from sleep apnea? Find out!

Answer the questions below, and we'll send you the results within 48 hours.

Name

Phone

Email

Please contact me with my results by:




Height

Weight

Gender

Neck Circumferencet

Collar size of shirt

Snoring

Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?


Tired

Do you often feel tired, fatigued, or sleepy during daytime?


Observed

Has anyone observed you stop breathing during your sleep?


Blood Pressure

Do you have or are you being treated for high blood pressure?


How sleepy are you?

How likely are you to doze off or fall asleep in the following situations?

Use the following scale to choose the most appropriate number for each situation:

0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing

Sitting and reading

Watching TV

Sitting, inactive in a public place (e.g. a theater or meeting)

As a passenger in a car for a hour without a break

Sitting and talking to someone

Sitting quietly after a lunch without alcohol

In a car, while stopped for a few minutes in traffic










Banner Enabled? ('Y' or 'N') Y

NOTICE

Please be aware, there is currently a scam on Instagram using our practice name and asking for money to pay for implants or other services. Our office is aware of the scam and is actively working to have it removed. At no time will our office request payment information through social media.

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