Name *

First Name

Last Name

Date Of Birth *

MM

DD

YYYY

Have you undergone a sleep test before? *

Yes

No

Were you DIAGNOSED SLEEP APNEA: *

If NO, advance to "Sleep History"

Yes

No

If YES, are you on CPAP?

Yes

No

Dental Appliance

Yes

No

Snoring with treatment (CPAP or dental appliance)?

Yes

No

Apnea with treatment (CPAP or dental appliance)?

Yes

No

Tiredness with treatment (use of CPAP or dental appliance)?

Yes

No

Snoring *

Yes

No

Pause/Stop *

Yes

No

Gasp for breath *

Yes

No

Cough/Choking

Yes

No

Jerking/Jumping of legs *

Yes

No

Night sweats *

Yes

No

Do you feel refreshed upon awakening? *

Yes

No

Do you have headaches upon awakening? *

Yes

No

TIREDNESS DURING THE DAY *

Yes

No

Intentional napping?

Yes

No

Asthma *

Yes

No

Bronchitis *

Yes

No

Emphysema *

Yes

No

COPD *

Yes

No

Known Cardiac Arrhythmia? *

Yes

No

Atrial Fibrillation? *

Yes

No

Pacemaker *

Yes

No

Hypertension *

Yes

No

Heart Attack/Myocardial Infarction *

Yes

No

Stent? *

Yes

No

Do you grind your teeth at night? *

Yes

No

Do you have all your teeth? *

Yes

No

Tonsils? *

IN

OUT

Dry mouth *

Yes

No

Do you smoke/vape? *

Yes

No

Do you drink alcohol?

Yes

No

Glass of

Beer

Wine

Hard liquor

How much?

Daily

Weekly

Other

Patient Name *

First Name

Last Name

Please mark if you experience any of the following symptoms *

Snoring

Stop breathing during sleep

Daytime sleepiness

Morning breathing

Sleepwalking

Sleeptalking

Complex behaviours during sleep

Teeth grinding

Bedwetting

Restless leg syndrome

Vivid dreams

Sleep paralysis

Acting out dreams

Muscular weakness triggered by emotion

Previously diagnosed sleep apnea