Sleep Apnea, Obstructive Sleep Apnea (OSA) and Snoring - Apnea.com

Sleep Apnea Questionnaire

Please answer each question carefully and accurately. All questions must be answered to correctly process and analyze your responses.

Have you been treated for any of the following Conditions/Symptoms? (Answer every question)
High Blood Pressure	Yes No
Heart Disease	Yes No
Stroke	Yes No
Insomnia	Yes No
Nocturia (frequent urination at night)	Yes No
Erectile Disfunction	Yes No
Depression	Yes No
Diabetes	Yes No
Overweight	Yes No

	Never	Sometimes (1-3 times/week)	Always (5-7 times/week)
Do you snore?	Never	Sometimes	Always
Do you or have you been told you stop breathing while you sleep?	Never	Sometimes	Always
Do you wake during the night?	Never	Sometimes	Always
Do you suddenly wake-up gasping for air?	Never	Sometimes	Always
Do you wake in the morning feeling tired?	Never	Sometimes	Always
Do you wake in the morning with a headache?	Never	Sometimes	Always

Do you find yourself getting sleepy, falling asleep or dozing off during any of the following situations?		Never	Sometimes	Often
	Sitting and reading?	Never	Sometimes	Often
	Watching TV?	Never	Sometimes	Often
	Sitting, inactive in a public place (eg., theater, meeting)?	Never	Sometimes	Often
	As a passenger in a car for an hour without a break?	Never	Sometimes	Often
	Lying down to rest in the afternoon when circumstances permit?	Never	Sometimes	Often
	Sitting and talking to someone?	Never	Sometimes	Often
	Sitting quietly after lunch without alcohol?	Never	Sometimes	Often
	In a car, while stopped for a few minutes at a traffic light?	Never	Sometimes	Often

Sleep Apnea can be a serious condition. This free service is for people like you who are interested in having their answers reviewed by a physician at absolutely no charge. Therefore, the physician will require some basic information in case your questionnaire results are positive and you need to be contacted regarding your options. Of course, your results and information are considered private and protected information under Federal and State laws.
First Name	Required
Last Name	Required
Phone (area code \| number)	Required
Email Address	Required
State	Required Sorry, this program is currently for U.S. residents only.

Important Notice

All Conditions/Symptoms questions must be answered to correctly analyze your condition. Please complete these selections.