Snoring Intake Questionnaire Form
Please complete this form to help us understand your snoring concerns. All questions are designed for a basic intake and do not request sensitive health information.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
How often do you snore?
*
Every night
Most nights
Occasionally
Rarely
Never
How loud is your snoring typically?
*
Very loud (can be heard through closed doors)
Moderately loud (disturbs others in the same room)
Mild (barely noticeable)
I am not sure
Have you or others noticed any of the following symptoms during your sleep? (Select all that apply)
*
Pauses in breathing
Choking or gasping
Restless sleep
Daytime sleepiness
Morning headaches
None of the above
How would you rate your overall sleep quality?
*
Excellent
Good
Fair
Poor
What is your typical sleep position?
*
Back
Side
Stomach
Varies
Do you have any of the following contributing factors? (Select all that apply)
Allergies
Nasal congestion
Overweight
Alcohol consumption
Smoking
None of the above
Is there anything else about your snoring or sleep you would like to share?
Submit
Should be Empty: