top of page

Sleep Questionnaire

Please take a few minutes to answer the following questions.  If either you or your bed partner has a response of three or more, you could be at risk and should have a comprehensive evaluation.


Note:  You may assess your bed partner’s probability of having Sleep Disordered Breathing as well by answering the questions based on your knowledge.

1.    Heavy breathing sounds, snore, sigh or snort when sleeping.
2.    My snoring affects people at home or away.
3.    Have been told or wake myself up with a snort, choke or gasping for air during sleep.
4.    Difficult to fall asleep or get back to sleep once awake, wake frequently during the night.
5.    Thyroid disorder or diabetes.
6.    Nap intentionally, am excessively sleepy during the day, fall asleep easily (i.e. in a meeting or watching TV or movies).
7.    Frequent: nasal congestion, difficulty breathing through your nose, mouth breathing or allergies.
8.    I have or had high blood pressure, irregular heartbeats, heart attack, stroke, or coronary artery disease.
9.    Morning headaches or feel groggy for a while after waking in the morning or must use the snooze button many times.
10.    Depression, mood disorder or anxiety.
11.    I am significantly over weight.
12.    I often feel tired, fatigued or lethargic.
13.    My memory is poor; I have difficulty concentrating.
14.    Neck size: men 17 in. or more, women 16 in. or more.
15.    Age: Men over 40, women over 50 or menopausal
16.    I often require sleeping pills, sedatives or pain medication to sleep.
17.    CPAP USERS: I don’t use it all night, stopped using it or don’t feel much better whether I use it or not.

If you want an appointment with us for a detailed assessment, please Book an Appointment.

bottom of page