Name: Advanced Dental Sleep Treatment Center
Address: 11919 Grant Street, Suite 140, Omaha, NE, 68164
Telephone: (402) 493-4175

Gender*

Male
Female

Have you been told you have sleep apnea?*

Yes
No

Are you being treated all night, every night without issues (i.e. wearing a CPAP or sleep apnea oral appliance all night, every night)?*

Yes
No

Have you ever been told you stop breathing in your sleep?*

Yes
No

Has anyone ever mentioned to you that you snore?*

Yes
No

Body Mass Index more than 35?*

Not sure what your BMI is? Click Here

Yes
No

Please check if you have any of the following: *

-

Urination at night (nocturia)

Regular headaches

Acid reflux

Type 1 or Type 2 Diabetes

High blood pressure or heart disease

Males only - sexual dysfunction

Don't feel rested in the morning

Macular degeneration or glaucoma

Depression or anxiety

Past stroke

Insomnia

Tooth grinding

Memory problems

Frequent awakenings at night

Fatigue

None of the above

Based on your responses to this questionnaire, you may be at risk for sleep apnea, and we would highly recommend you pursue more information to find out. Untreated sleep disorders negatively affect your mental and cardiovascular health and well-being, but can be effectively treated.

Please indicate below if you'd like our team to follow-up with you to answer any questions you may have and/or to get you scheduled for an appointment.

Based on your responses to this quiz, you are not currently showing signs of sleep apnea. Keep in mind that this is not an official diagnosis and we recommend taking this quiz again in 6-12 months. If you are still concerned about your sleep health, please contact Advanced Dental Sleep Treatment Center at (402) 493-4175 with any questions or to schedule an overall sleep health appointment.

Please follow up with me regarding my results.

Please follow up with me regarding my results.

Email the results to me

Email the results to me

Name*

Email*

Phone*

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Name

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Sleep Apnea Risk Quiz

11919 Grant Street, Suite 140 Omaha, NE 68164

(402) 493-4175

11919 Grant Street, Suite 140
Omaha, NE 68164