Please fill in the following questionnaire to see if you or your partner suffer from a sleeping disorder. After filling in this questionnaire, we will provide you with more information on Sleeping Disorders in our Sleep Brochure Patient InformationFirst Name* Surname* Date of Birth (DD/MM/YYYY)* Phone* Doctor's Name (GP)* Address* Referring Specialist’s name* Medical ConditionsDo you have any conditions that your GP is aware of?Cardiovascular* Yes No Respiratory* Yes No Renal* Yes No Digestive* Yes No Neurological* Yes No Sleep Disorder QuestionsPlease tick yes or no. You may wish to confer with your bed partner for some of these questions1) Have you been told that you snore?* Yes No 2) Do you snore only when you are lying on your back?* Yes No 3) Do you snore chronically/loudly?* Yes No 4) Do you snore every night?* Yes No 5) Have you been told that you gasp or stop breathing during sleep?* Yes No 6) Has your partner ever had to move into another room during the night?* Yes No 7) Have you ever been treated for high blood pressure?* Yes No 8) Do you doze off during the day?* Yes No 9) Do you often wake feeling tired or not refreshed?* Yes No 10) Do you often wake with a headache in the morning?* Yes No 11) Do you have problems with concentration?* Yes No 12) Do you experience pain in your jaw joints (located near the ear)?* Yes No 13) Do you clench or grind your teeth in your sleep?* Yes No 14) Have you ever been diagnosed or suspect you have Obstructive Sleep Apnoea?* Yes No 15) Have you ever been seen by a specialist for snoring or Obstructive Sleep Apnoea?* Yes No 16) Have you ever undertaken a sleep study?* Yes No 17) Have you ever been treated for snoring, Obstructive Sleep Apnoea or a sleep disorder?* Yes No Family HistoryHave any of your family members experienced heart disease/high blood pressure/ diabetes?* Yes No Do any of your family members snore, have Obstructive Sleep Apnoea or a sleep disorder?* Yes No Personal InformationHeight* Weight* Neck circumferenceMale greater than 43cm Yes No Female greater than 41cm Yes No Alcohol consumption* (units per week)CAPTCHA Don’t forget to share this via Twitter, Google+, Pinterest and LinkedIn.