Grand Prairie Family Dental

2475 W Pioneer Pkwy, Grand Prairie, TX 75051

(972) 945-3872

Adult Sleep Apnea Questionnaire

Gain valuable insights into your eligibility for this transformative sleep solution.

Answer the questions below to see if you are a candidate for our dental sleep solution

Do You Snore? *

No Occurrence

Occurs Rarely

Occurs 2-4 Times Per Week

Occurs 5-7 Times Per Week

Interrupted snoring where breathing stops *

No Occurrence

Occurs Rarely

Occurs 2 to 4 times per week

Labored, difficult or loud breathing at night? *

No Occurrence

Occurs Rarely

Occurs 2 to 4 times per week

Occurs 5 to 7 times per week

Gasping for air while sleeping? *

No Occurrence

Occurs Rarely

Occurs 2 to 4 times per week

Occurs 5 to 7 times per week

Mouth breathes while sleeping? *

No Occurrence

Occurs Rarely

Occurs 2 to 4 times per week

Occurs 5 to 7 times per week

Mouth breathes during day? *

No Occurrence

Occurs Rarely

Occurs 2 to 4 times per week

Occurs 5 to 7 times per week

Restless sleep? *

No Occurrence

Occurs Rarely

Occurs 2 to 4 times per week

Occurs 5 to 7 times per week

Grinds teeth while sleeping? *

No Occurrence

Occurs Rarely

Occurs 2 to 4 times per week

Occurs 5 to 7 times per week

Talks in sleep? *

No Occurrence

Occurs Rarely

Occurs 2 to 4 times per week

Occurs 5 to 7 times per week

Excessive sweating while sleeping? *

No Occurrence

Occurs Rarely

Occurs 2 to 4 times per week

Occurs 5 to 7 times per week

Wakes up at night? *

No Occurrence

Occurs Rarely

Occurs 2 to 4 times per week

Occurs 5 to 7 times per week

Feels sleepy and/or irritable during the day? *

No Occurrence

Occurs Rarely

Occurs 2 to 4 times per week

Occurs 5 to 7 times per week

Seasonal allergies? *

No Occurrence

Occurs Rarely

Occurs 2 to 4 times per week

Occurs 5 to 7 times per week

Trouble focusing? *

No Occurrence

Occurs Rarely

Occurs 2 to 4 times per week

Occurs 5 to 7 times per week

ADD/ADHD? *

Yes

No

Full Name *

Email *

Phone *

Terms & Conditions