Sleep Apnea Survey

Do you or your partner suffer from
snoring, daytime sleepiness or morning headaches?

At Marx Family Dental we not only care about your oral health and smile, but we also are interested in your overall health. Therefore, we would appreciate it if you would thoughtfully fill out this survey with a yes or no after each question. Then send it back to us so we can set up a consultation to help you on your journey to a more enjoyable and better quality of life.

Sleep Apnea Survey

Sleep Apnea Survey

1. Has anyone told you that you snore? *

Yes

No

2. Do you suffer from daytime sleepiness? *

Yes

No

3. Do you have a bed partner who snores? *

Yes

No

4. Do you fall asleep frequently when sitting inactive (tv, theatre, a meeting)? *

Yes

No

5. Have you experienced morning headaches? *

Yes

No

6. Are you frustrated with you CPAP and looking for an alternative? *

Yes

No

7. Do you wake up tired? *

Yes

No

Name *

Email *

Phone *

Comments

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