Sleep Apnea Questionnaire You can use this brief questionnaire to help determine if you might be suffering from Sleep Apnea. "*" indicates required fields Name* First Last Email* PhonePlease select the following medical conditions you have or think you might have: Depression Anxiety Type 2 diabetes Insomnia High blood pressure Congestive heart failure Parkinson’s disease Polycystic ovary syndrome Prior stroke Asthma Large neck circumference Acid Reflux Obesity N/A Please select the following symptoms you experience during your sleep: Breakage in breathing Choking and/or gasping for air Frequent bathroom breaks Loud snoring Difficulty staying asleep Teeth Grinding N/A Please select the following symptoms you experience during the day: Irritability Daytime sleepiness Morning headaches Difficulty paying attention Dry mouth N/A CommentsThis field is for validation purposes and should be left unchanged.