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Snoring Questionnaire
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Snoring Questionnaire
Snoring Questionnaire
aurshax
2019-01-04T17:57:07+00:00
Snoring Questionnaire
Name
*
First
Last
Date
*
Date Format: MM slash DD slash YYYY
Do you snore?
*
Yes
No
How long have you snored? (in Years)
What is your present height?
What is your present weight?
Do you awake with a headache?
Yes
No
How many times weekly?
Do you awake with a dry mouth?
Yes
No
Do you have trouble breathing through your mouth or do you Feel like something is in your throat?
Yes
No
Do you awake rested most of the time?
Yes
No
Do you get recurrently sleepy during the day at times other than after lunch?
Yes
No
Do you doze/nod off when you are inactive?
Yes
No
Have you ever awakened with the feeling that you could not breathe?
Yes
No
Have you ever been told that you stop breathing while you are asleep?
Yes
No
Do you have shortness of breath?
Yes
No
How many times a day?
How many times per week?
Have you been diagnosed with sleep apnea?
Yes
No
By whom?
When (Approximately)
Date Format: MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.
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