Leone & Vaughn

Name:

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Todays Date:

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Please answer the following questions with YES, NO or DON’T KNOW as they pertain to you in the past month.

While sleeping do you:

Snore more than half the time?

Always snore?

Snore loudly?

Have ‘heavy’ or loud breathing?

Have trouble breathing/struggle to breathe?

Have you ever stop breathing during the night?

Has your physician ever recommended you be evaluated for a sleep study?

Do you:

Tend to breathe through the mouth during the day?

Have a dry mouth upon waking in the morning?

Do you wake up with headaches in the morning?

Do you find yourself?

Feeling tired during the day?

Having difficulty organizing tasks and activities

Fidgeting with hands or feet?