Sleep Apnea Disability Exam Questionnaire Form
Please complete this assessment to help us understand your sleep apnea symptoms, their impact, and related history. This information is used for your sleep apnea disability exam intake.
How often do you experience loud snoring?
*
Never
Rarely (less than once a week)
Sometimes (1-2 times per week)
Often (3-4 times per week)
Almost always (5 or more times per week)
How frequently do you feel excessively sleepy or tired during the day?
*
Never
Rarely
Sometimes
Often
Almost always
Has anyone observed you stop breathing during your sleep?
*
No
Yes, rarely
Yes, occasionally
Yes, frequently
Don't know
How would you rate your overall sleep quality?
*
1
2
3
4
5
How much does sleep apnea impact your daily activities (e.g., work, driving, concentration)?
*
No impact
1
2
3
4
Severe impact
5
1 is No impact, 5 is Severe impact
Do you currently use a CPAP machine or other sleep apnea treatment?
*
No
Yes, CPAP
Yes, oral appliance
Yes, other treatment
If using a treatment, how often do you use it?
*
Not applicable
Every night
Most nights
Some nights
Rarely
Please indicate any of the following symptoms you have experienced in the past month (select all that apply):
*
Morning headaches
Waking up with dry mouth
Difficulty staying asleep
Nighttime choking or gasping
Restless sleep
None of the above
How likely are you to doze off or fall asleep in the following situations?
*
Rows
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Sitting and reading
1
2
3
4
Watching TV
5
6
7
8
Sitting inactive in a public place
9
10
11
12
As a passenger in a car for an hour without a break
13
14
15
16
Lying down to rest in the afternoon
17
18
19
20
Sitting and talking to someone
21
22
23
24
Sitting quietly after lunch
25
26
27
28
In a car, while stopped for a few minutes in traffic
29
30
31
32
Submit
Should be Empty: