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Sleep Apnea Quiz PDF
Sleep Apnea Quiz (SAQ) 2017
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Indicates required field
First Name
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Last Name
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D O B
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Month/Date/Year
Age
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Gender
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Select One
Male
Female
Day
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Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Month
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January
February
March
April
May
June
July
August
September
October
November
December
Status
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Select One
Single
Maried
Separated
Divorced
Widowed
SITUATION
Have you been told that you SNORE?
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Select One
Yes
No
I’ve been told that I STOP breathing while I sleep.
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Select One
Yes
No
I have HIGH blood pressure.
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Select One
Yes
No
My family say they have noticed CHANGES in my personality.
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Select One
Yes
No
I am GAINING weight.
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Select One
Yes
No
I sweat EXECESSIVELY during the night.
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Select One
Yes
No
I have noticed my HEART pounding or beating irregularly at night.
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Select One
Yes
No
I get morning HEADACHES.
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Select One
Yes
No
I have TROUBLE sleeping when I have a cold.
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Select One
Yes
No
I suddenly wake up GASPING for breath during the night.
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Select One
Yes
No
I am OVERWEIGHT.
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Select One
Yes
No
I seem to be LOSING my sex drive.
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Select One
Yes
No
I feel TIRED during the day even when I sleep through the night.
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Select One
Yes
No
If you marked Yes three or more times, you may show symptoms of Sleep Apnea, a life-threatening disorder that causes you to stop breathing repeatedly often several hundred times a night while you sleep.
This questionnaire is meant to be a source of education to help you and your physician decide if you need help or further evaluation. It should not be used for diagnosis or treatment purposes.
If you show symptoms of a sleep disorder for more than two weeks, please take this form to your physician.
Sleep Study at the comfort of your home using SOMNOscreen™ plus, the smallest state of the art wireless PSG system with up to 28 channels or ApneaLink Plus, that will allow you to move freely anywhere in your home without any tech assistance. Tel: (305) 606-5332 • e-mail:
info@conciergesleepmedicine.com
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