Sleep Apnea Quiz

Sleep Apnea Quiz PDF

Sleep Apnea Quiz (SAQ) 2017

* Indicates required field

First Name *

Last Name *

D O B *

Age *

Gender *

Day *

Month *

Status *

SITUATION

Have you been told that you SNORE? *

I’ve been told that I STOP breathing while I sleep. *

I have HIGH blood pressure. *

My family say they have noticed CHANGES in my personality. *

I am GAINING weight. *

I sweat EXECESSIVELY during the night. *

I have noticed my HEART pounding or beating irregularly at night. *

I get morning HEADACHES. *

I have TROUBLE sleeping when I have a cold. *

I suddenly wake up GASPING for breath during the night. *

I am OVERWEIGHT. *

I seem to be LOSING my sex drive. *

I feel TIRED during the day even when I sleep through the night. *

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

Submit