Document

Lehigh Valley Cosmetic Dentistry

Your Smile is in Safe Hands

Adult Airway and Sleep Questionnaire

Go Back To Home!

Patient Name

Phone

Do you snore loudly or have you been told that you snore ?

Yes

Do you ever awaken with the sensation of gasping or choking ?

Yes

Has anyone ever noticed that you stop breathing during your sleep ?

Yes

Do you often wake up with dry mouth ?

Yes

Do you find your sleep to be non-refreshing ?

Yes

Do you often feel tired, fatigued, or sleepy during daytime ?

Yes

Do you ever fall asleep or nod off in situations where you did not
intend to ?

Yes

Do you have (or are you being treated for) high blood pressure
and/or diabetes ?

Yes

Do the edges of your tongue have a scalloped pattern ?

Yes

Do you grind your teeth while sleeping ?

Yes

Do your front teeth have a worn look ?

Yes

Are your teeth crowded or jaws misaligned ?

Yes

Do you experience heartburn at night or when you
wake up in the morning ?

Yes

Have you or your dentist noticed erosion on your molars ?

Yes

Do you have frequent headaches ?

Yes

Do you have frequent neck pain or soreness ?

Yes

Do you have difficulty breathing through your nose ?

Yes

Do you have a chronic cough ?

Yes

Do you have jaw muscle or joint pain, ringing in your ears,or dizziness ?

Yes

Have you been diagnosed with ADHD ?

Yes

If you have answered YES to 3 or more questions from the top 8 , you are a candidate for a Home Sleep Test to be evaluated for the presence of Obstructive Sleep Apnea.

If you've answered YES to 3 or more questions overall , you are showing signs and symptoms of Sleep Related Disordered Breathing.

Signature

Date