Here is the FREE Sleep Apnea Self-Questionaire.

Sleep Apnea Self-Questionaire.

Do you or did someone say you snore? Y or N

Do you have trouble sleeping? Y or N

Do you use a CPAP machine? Y or N

How long have you used a CPAP machine? _________

Do you wake at night? Y or N How often? _________

Why do wake at night? __________________________

Does someone say you wake at night? Y or N

How often do they say? _____ X’s

Do you or did someone say you stop breathing at night? Y or N How often? ______________

Do you have jaw pain? (TMJ) Y or N

Are you tired during the day? Y or N

Do you have dry mouth often? Y or N

Do you have neck pains? Y or N

Feel in the morning – Rested, Tired, Exhausted, Other ? _________

Do you take or want to take a nap during the day? YorN How many naps? ________

Do you smoke? Y or N _______________

How many hours of sleep at night do you get? ________

Do you have a drop in energy during the day? Y or N

Do you have jumpy or restless legs at night? Y or N

Do your eyes feel tired? Y or N ________

Headaches? Y or N How frequently? x/day, wk, mo ___

Migraines? Y or N How frequently? x/day, wk, mo ___

Do you have dry issues? Y or N

Is it difficult to swallow? Y or N

Do you have a tight feeling around the throat? Y or N

Do you always have to clear your throat? Y or N

Do you have frequent “negative” dreams or nightmares? Y or N

Do you have or have had: (circle all that apply) High Blood Pressure    Depression     Heart Attack     Stroke/TIA
                                                                            Erectile Dysfunction     Asthma

***DISCLAIMER***  - This Self-Questionaire is not designed to diagnose any condition.  It is a SELF questionaire.