Consumer Sleep Apnea Questionnaire

Do you snore?
Yes No

Does your snoring bother other people?
Yes No

Has anyone ever noticed that you stop breathing during sleep?
Yes No

Are you tired after sleeping?
Yes No

Have you ever dozed off or fallen asleep while driving?
Yes No

Has anyone ever told you that you jerk your legs (or your arms) when you are asleep; do you sometimes, have involuntary leg jerks when you are awake?
Yes No

Do you have trouble falling asleep or staying asleep?
Yes No

Do you ever fall asleep at inappropriate times (while working, eating, talking, and driving)?
Yes No

Have you ever suddenly fallen without due cause?
Yes No

Have you ever experienced sudden body weakness brought on by laughter, surprise, or fear?
Yes No

Have you ever experienced seeing or hearing things that were not real when you were going to sleep or just waking up?
Yes No

Does anyone in your family have a sleep disorder?
Yes No

If so, who is it, and what kind of sleep disorder is it?

How long does it usually take you to fall asleep after turning out the lights?

On average, how many times do you wake up during the night?

On average, how many times do you get up out of bed during the night?

Please list any medical conditions that you have:

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