Sleep Disorder Questionnaire | Regina Dentist

Sleep Disorder Questionnaire | Health Style Dental

Are you experiencing any issues with snoring, sleep apnea or using a CPAP machine? Please fill out the form below and we will follow up with you to address your issues with some helpful insights.

Part 1: Your Contact Information

Please provide us with the following information so we can follow-up with you within 48-hours.

First Name *

Last Name *

Email Address *

Phone *

What is the best way for us to contact you? *

Phone

Part 2

Please rate each of the following situations based on how likely you are to doze or fall asleep (just feeling tired).

As a passenger in a car for an hour without a break *

In a car, while stopping for a few minutes in traffic *

Sitting quietly after a lunch without alcohol *

Sitting and talking to someone *

Lying down to rest in the afternoon *

Sitting inactive in a public place (like a movie or a meeting) *

Sitting and reading *

Watching television *

Part 3

Do you snore? *

If you snore, how often do you snore?

If you snore, how loud do you snore?

If you snore, has your snoring every bothered other people?

Has anyone noticed that you quit breathing during your sleep? *

How often do you feel tired or fatigued after your sleep? *

During your awake time, do you feel tired, fatigued, or not up to par? *

Have you ever nodded off or fallen asleep driving a vehicle? *

If you have ever nodded off or fallen asleep driving a vehicle, how often does this occur?

Do you have high blood pressure? *

Please provide any additional information you think might be helpful:

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