Adult Sleep Questionnaire

Adult Sleep Questionnaire
While Sleeping Do You....
Snore more than half the time?*

YesNoI Don't Know
Always snore?*

YesNoI Don't Know
Snore loudly?*

YesNoI Don't Know
Have ‘heavy’ or loud breathing?*

YesNoI Don't Know
Have trouble breathing or struggle to breathe?*

YesNoI Don't Know
Have you ever stopped breathing while sleeping?*

YesNoI Don't Know
Do You....
Tend to breathe through the mouth during the day?*

YesNoI Don't Know
Have a dry mouth on waking up in the morning?*

YesNoI Don't Know
Wake up feeling un-refreshed in the morning?*

YesNoI Don't Know
Have problems with sleepiness during the day?*

YesNoI Don't Know
Is it hard for you to wake up in the morning?*

YesNoI Don't Know
Do you wake up with headaches in the morning?*

YesNoI Don't Know
Did you stop growing at a normal rate at any time since birth?*

YesNoI Don't Know
Are you overweight?*

YesNoI Don't Know
Total number of YES responses:*
If eight or more statements are answered “yes”, consider referring for sleep evaluation.
Patient Name*
Email*
example@example.com
Should be Empty:

While Sleeping Do You....