Sleep Health Assessment - SleepHealthAssessment.com

Sleep Apnea History

First, let's understand your sleep apnea history and current treatment status.

Have you ever been diagnosed with obstructive sleep apnea?

Yes No

Based on your sleep test, how severe is your sleep apnea?

Mild Moderate Severe I Don't Remember

Please select the therapy you were prescribed as treatment for your sleep apnea.

CPAP Oral Appliance Other None

Please describe the other therapy you are using.

How many days per week do you use your current sleep apnea therapy?

0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days

Now let's assess your current sleep-related symptoms.

Do you snore?

Yes No Not Sure

Have you been told you stop breathing, gasp for breath or choke during sleep?

Yes No

Do you wake up with a dry mouth?

Yes No

Let's understand how sleep affects your daily life.

To what extent do you consider poor sleep to interfere with your daily functioning (e.g. daytime fatigue, mood, etc.)?

No Interference Some Interference A Lot of Interference

How likely are you to doze off or fall asleep in the following situations? Choose the most appropriate number for each situation:

0 = No chance | 1 = Slight chance | 2 = Moderate chance | 3 = High chance

Sitting and reading