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Partner Questionnaire
Sleep Apnea & Snoring Questionnaire
Payment
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Partner Questionnaire
Please answer the following questions as they pertain to your bed partner in the last month
First name
Person Completing Form
Does your partner, snore more than half the time?
Yes
No
Don't know
Does your partner, always snore?
Yes
No
Don't know
Does your partner, snore loudly?
Yes
No
Don't know
Does your partner, have heavy or loud breathing?
Yes
No
Don't know
Does your partner, have trouble breathing or struggle to breath?
Yes
No
Don't know
Have you ever heard your partner stop breathing during the night?
Yes
No
Don't know
Does your partner ever have snoring or choking episodes during the night?
Yes
No
Don't know
Does your partner, tend to breath through their mouth?
Yes
No
Don't know
Does your partner, have dry mouth on waking up in the morning?
Yes
No
Don't know
Does your partner, occasionally wet the bed?
Yes
No
Don't know
Have you ever experienced your partner, grinding their teeth during the night?
Yes
No
Don't know
Have you ever experienced your partner, have twitching or kicking of their arms or legs?
Yes
No
Don't know
Does your partner wake up refreshed in the morning?
Yes
No
Don't know
Does your partner have a problem with sleepiness during the day?
Yes
No
Don't know
Is it hard for you to wake your partner up in the morning?
Yes
No
Don't know
Does your partner wake up with headaches in the morning?
Yes
No
Don't know
Is your partner overweight?
Yes
No
Don't know
Submit
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About
Services
Areas of Care
Contact
Testimonials
Sleep Better
Partner Questionnaire
Sleep Apnea & Snoring Questionnaire
Payment
Contact
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