Sleep profile
Are you able to breathe through your nose?
Yes, I am able to breathe through my nose
No, I am unable to breathe through my nose
I am able to breathe through my nose during the day, but I am unable to breathe through nose at night only
How do you describe your sleep?
I sleep the full night
I toss and turn
I can’t stay asleep
I can’t fall asleep at all
Do you experience any of the following when you wake up?
Dry mouth
Sore throat
Nasal congestion
How do you usually sleep?
Sleep on back
Sleep on side
Sleep on stomach
Other
How would you describe your sleeping pattern? Select all that apply
Open mouth snorer
CPAP user
Non-snorer
Oral appliance user
If you are a CPAP user, why type of mask do you use?
Nasal Mask
Full face mask
Have you had surgery for sleep issues?
Yes, I have had surgery for any sleep issues
No, I have not had surgery for any sleep issues
How is your mood generally?
Angry
Anxious
Irritable
Depression
Nervous
Stressed
Sad
Do you have any of the following cardiovascular issues?
Hypertension/high blood pressure
Hypotension/low blood pressure
Irregular heartbeat
Rapid heart rate
Heart rate too slow
Heart attack
Stroke
Do you have any of the following cognitive issues?
Difficulty concentrating
Headache
Mental fogginess
Migraines
Forgetfulnes
Do you experience any of the following?
Libido issues
Menstrual period issues
Pregnant
BMI
Chart (images)
Have you experienced any of the following dental conditions?
Tooth crowding
Teeth removed (specifically to make space for braces)
Missing teeth
High incidence of cavities
Gingivitis
Receding gums