What specifically is the reason for your visit?
Your goals for seeking sleep apnea treatment include:
Do you have other treatment goals?
What was your weight 1 year ago?
What was your weight at age 18?
Yes
No
I don't know
How loudly do you snore? (0-10)
How long have you been a snorer? (years)
Has your snoring worsened lately?
Yes
No
I don't know
How severe is your snoring? Move the marker to the location that indicates how disruptive your snoring is to you and your bed partner.
Do you hold your breath or gasp for air while asleep?
Yes
No
I don't know
What makes your snoring or breathing patterns at night better or worse (for example, sleeping on back vs. side, alcohol intake, nasal blockage, being tired)?
What is your usual WEEKDAY BEDTIME and WAKEUP time? (ie. 9pm-6am)
What is your usual WEEKEND BEDTIME and WAKEUP time?
How long does it take you to fall asleep at night (minutes)?
How many times do you wake up at night?
How long to fall back asleep? (minutes)
Do you feel refreshed when you wake up in the morning?
Always
Sometimes
Rarely
Never
Always
Sometimes
Rarely
Never
Do you frequently awaken with (check all that apply):
How does fatigue limit your daily activities?
None
Mild
Moderate
Severe
How many caffeinated beverages (coffee, tea, or soda) do you drink each day?
Do you have trouble swallowing? Move the marker to the location that indicates your difficulty in swallowing
How much has obstructive sleep apnea affected your life and day-to-day functional status?
Have you used positive airway pressure therapy (CPAP, BiPAP, or AutoPAP)?
Yes
No
Describe your experience with CPAP/BiPAP/AutoPAP, including the reasons for not wearing it if you are not able to?
On average, how many NIGHTS A WEEK are or were you able to wear it?
For how many HOURS PER NIGHT? Give range or average
Are you still using CPAP/BiPAP/AutoPAP?
Yes
No
What type of masks do you use or have you used? Choose all that apply.
When you used CPAP, did you feel your overall sleep symptoms were better?
Yes, I felt better
No, It was not better
I don't know
Yes, I felt better
No, It was not better
I don't know
Have you ever used an oral appliance?
Yes
No
If yes, what is/was your experience?
Do you feel a restless sensation in your legs while lying awake in bed?
Yes
No
Experience sudden loss of strength in your arms or legs during the day?
Yes
No
If yes, is this brought on by sudden fright or laughter?
Yes
No
View equation Do you have difficulty breathing through your nose?
Yes
No
Is breathing through your nose a problem during the day?
Yes
No
Is breathing through your nose a problem during the night?
Yes
No
One-side - right
One-side - left
Both sides
Alternates sides
One-side - right
One-side - left
Both sides
Alternates sides
Does your nasal blockage change with the time of year (seasons)?
Yes
No
If so, what seasons or situations cause worse symptoms?
Do you have symptoms of allergies, such as itchy or watery eyes or hay fever?
Yes
No
What medications or devices have you tried to treat nasal obstruction, and what has
Nasal Obstructive Symptom Evaluation Score
View equation Move the marker along the line to show how troublesome is your difficulty in breathing through your nose?
1
2
3
4
5
6
7
8
9
10
View equation What types of treatment do you want to learn more about?
If you had to choose today, which therapies are you most interested in using or proceeding with?
Would you be ok with us contacting you in a few months to ask about your sleep symptoms and any treatment decisions?
Yes
No
If so, please provide the best email address for us to contact you.
Submit
Save & Return Later
Working...