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Sleep Study Questionnaire

Have you ever had an evaluation at a Sleep Center?

CPAP (Continuous Positive Airway Pressure) Intolerance

If you have attempted treatment with a CPAP device, but could not tolerate it, please fill in this section.

Other Therapy Attempts

What other therapies have you had for breathing disorders? (Weight-loss attempts, smoking cessation for at least one month, surgeries, etc.)

Do You Snore?

If you snore...

How loud do you snore?
During your waketime, do you feel tired, or not up to par?
How often do you snore?
Have you ever nodded off or fallen asleep while driving a vehicle?
Does your snoring bother other people?
If yes, how often does it occur?
Has anyone noticed that you quit breathing during your sleep?
Do you have high blood pressure?
How often do you feel tired or fatigued after you sleep?


The Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations?

Sitting and reading
Lying down to rest in the afternoon when circumstances permit
Sitting in a public place (e.g.: theatre, meeting or church)
Sitting and talking to someone
As a passenger in a car for an hour without a break
In a car, while stopped for a few minutes in traffic
Watching TV