Trillium Dental Downtown Minto Location Applicable Sleep Apnea Form Please check the box that best relates to your symptoms.*Required to fill for next section completion* I have been told that I snore My snoring is loud and bothers others I have been told that I stop breathing when I sleep I suddenly wake gasping for breath I frequently wake with a dry mouth I have problems breathing through my nose I have noticed my heart pounding or beating irregularly during the night I often wake up with headaches My friends and family say that I’m grumpy and irritable I have fallen asleep while driving I often fall asleep as a passenger in a vehicle for an hour or more I tend to nod off watching TV, reading or sitting quietly I am often tired through the day I often feel sleepy during the day and struggle to remain alert I have trouble concentrating at work I am overweight I have high blood pressure None of the above (Q 1 – 17: If you marked 3 or more boxes, you show symptoms of Sleep Apnea) Please check the next section that applies. If not please check no.* No I have not marked 3 or more boxes. I have seen a doctor about snoring or sleep apnea. I have had a lab sleep study. Required to fill for next section completion"I suffer from memory loss." Yes No Please provide additional detailsRequired to fill for next section completion* I suffer from depression I have a problem with my jaw My jaw locks My jaw hurts My jaw clicks I often clench and/or grind my jaw None of the Above Please submit your first and last name below. Both are required.* First Last Date* MM slash DD slash YYYY
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