Adult Sleep Questionnaire

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

Yes No I Don't Know
Always snore? *

Yes No I Don't Know
Snore loudly? *

Yes No I Don't Know
Have ‘heavy’ or loud breathing? *

Yes No I Don't Know
Have trouble breathing or struggle to breathe? *

Yes No I Don't Know
Have you ever stopped breathing while sleeping? *

Yes No I Don't Know
Do You....
Tend to breathe through the mouth during the day? *

Yes No I Don't Know
Have a dry mouth on waking up in the morning? *

Yes No I Don't Know
Wake up feeling un-refreshed in the morning? *

Yes No I Don't Know
Have problems with sleepiness during the day? *

Yes No I Don't Know
Is it hard for you to wake up in the morning? *

Yes No I Don't Know
Do you wake up with headaches in the morning? *

Yes No I Don't Know
Did you stop growing at a normal rate at any time since birth? *

Yes No I Don't Know
Are you overweight? *

Yes No I 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....