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100 Ridge Road, Suite 36
Chadds Ford, PA 19317
610.558.1760
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Sleep Apnea Questionnaire
Simply complete the form below and someone from our dental team will contact you soon.
S
: Do you snore
loudly
(louder than talking or loud enough to be heard through closed doors)?
Yes
No
T
: Do you often feel
tired
, fatigued or sleepy during the day?
Yes
No
O
: Has anyone
observed
you not breathing during sleep?
Yes
No
P
: Do you have or have you been treated for high blood
pressure?
Yes
No
You have a high risk of sleep apnea if you answered “yes” to two or more of these questions.
B
: Is your
Body Mass Index
more than 35 kg/m2?
Yes
No
A
: Is your
age
more than 50 years old?
Yes
No
N
: Is your
neck
circumference greater than 40 cm?
Yes
No
G
: Is your
gender
male?
Yes
No
You have a high risk of sleep apnea if you answered “Yes” to three or more of the eight STOP-Bang questions.
Name:
Email:
Date:
Phone:
Please enter code above in the field below.
