Sleep Apnea & Snoring Questionnaire

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Full Name*

How long have you been aware of your snoring?*

Has it caused problems for relatives or friends?*

Have you been told your breathing stops while asleep?*

Have you been told you move around a lot when you sleep?*

How many times per night do you wake up?*

Do you have difficulty falling asleep at night?*

How many hours of sleep per night do you get?*

Do you most often wake up feeling refreshed?*

Do you often wake up with a headache?*

Will a small amount of alcohol give you a hangover?*

Do you feel Sleepy during the day?*

Frequently

Occasionally

Seldom

Never

What other doctors have you seen about your snoring or sleep apnea?

Have you had a sleep lab study?*

Yes

No

Do you have difficulty breathing through your nose?*

Yes

No

Have you gained weight recently?*

Yes

No

What is your present body weight?*

What is your height?*

What professional treatment have you received about your snoring or sleep apnea?

Contact Us

9090 South Rodgers Court Southeast, Caledonia, Michigan 49316

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