Sleep Apnea Form

Please check the box that best relates to your symptoms.*

Required to fill for next section completion*

I have been told that I snore

My snoring is loud and bothers others

I have been told that I stop breathing when I sleep

I suddenly wake gasping for breath

I frequently wake with a dry mouth

I have problems breathing through my nose

I have noticed my heart pounding or beating irregularly during the night

I often wake up with headaches

My friends and family say that I’m grumpy and irritable

I have fallen asleep while driving

I often fall asleep as a passenger in a vehicle for an hour or more

I tend to nod off watching TV, reading or sitting quietly

I am often tired through the day

I often feel sleepy during the day and struggle to remain alert

I have trouble concentrating at work

I am overweight

I have high blood pressure

None of the above

(Q 1 – 17: If you marked 3 or more boxes, you show symptoms of Sleep Apnea) Please check the next section that applies. If not please check no.*

No I have not marked 3 or more boxes.

I have seen a doctor about snoring or sleep apnea.

I have had a lab sleep study.

Required to fill for next section completion

"I suffer from memory loss."

Yes

No

Please provide additional details

Required to fill for next section completion*

I suffer from depression

I have a problem with my jaw

My jaw locks

My jaw hurts

My jaw clicks

I often clench and/or grind my jaw

None of the Above

Please submit your first and last name below. Both are required.*

First Last

Date*

MM slash DD slash YYYY

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