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New Adult Sleep Apnea Quiz

Quizzes & Surveys


If you wish to change any of your responses, click the Back button.  If you are satisfied with your responses, click Submit.

Do you clench or grind your teeth?

Do you experience facial pain or tenderness?

How often do you experience ear pain or earaches?

How often do you experience headaches?

Have you ever experienced pain while chewing?

When opening and closing your mouth, does your jaw make a sound (e.g. clicking or popping)?

Do you often suffer from neck or back pain?

Have you ever experienced pain or numbness in your lower jaw?

Do you ever have trouble opening your mouth (your jaw locking up)?

Have you been to multiple doctors to address your pain?

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How often do you fall asleep while…

Sitting and reading?

Watching TV?

Sitting or lounging in a public place, such as a meeting, theater or dinner event?

Being a passenger in a car for an hour?

Lying down in the afternoon?

Sitting and talking to someone?

Sitting quietly after lunch (no alcohol)?

Stopping for a few minutes in traffic while driving?

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I. Breathing interruptions while sleeping

1. Have you ever seen your child stop breathing during the night?

II. Does your child...

1. Always Snore?

2. Snore more than half the time?

3. Snore Loudly?

4. Have "heavy" or loud breathing?

5. Have trouble breathing or struggle to breathe?

6. Tend to breathe through their mouth during the day?

7. Have a dry mouth on waking in the morning?

8. Occasionally wet the bed?

9. Wake up feeling unrefreshed in the morning?

10. Have a problem with sleepiness during the day?

11. Have a teacher or other supervisor who commented that your child sleeps during the day?

12. Find it hard to wake up in the morning?

13. Wake up with headaches in the morning?

III. Did your child stop growing at a normal rate at any time since birth?

IV. Is your child overweight?

V. My child often...

1. Does not seem to listen when spoken to directly.

2. Has difficulty organizing tasks and activities.

3. Is easily distracted by extraneous stimuli.

4. Fidgets with hands or feet or squirms in seat.

5. Is 'on the go' or often acts as if 'driven by a motor.'

6. Interrupts or intrudes on others (e.g. butts into conversations or games).

IF YOU ANSWERED YES TO ANY OF THE QUESTIONS ABOVE, YOUR CHILD MAY BE AT RISK OF SLEEP APNEA.

Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.

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