Sleep Apnea Assessment Form

Kigo Dental - Self Assessment form for sleep apnea

The following is a self-assessment to help you identify factors that may indicate you / your child have sleep apnea. The assessment is meant to be informative but does not substitute for a comprehensive evaluation by your dentist or healthcare provider to determine your actual risk and condition.

Sleep apnea

Be sure to answer all the questions honestly to obtain an accurate score. Hereafter "you" can be related to you, your child, or any person in need of taking this test.

A. Pauses in breathing
B. Restless sleep
C. Sweating heavily
D. Teeth grinding or clenching
E. Sleepwalking or sleeptalking
F. Bedwetting
G. Sleep in unusual positions with your head tilted back and neck extended
H. Shortness of breath, choking or gasping of breath

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Note: Please note that this self-assessment form does not intend to provide a definitive diagnosis if you / your child have sleep apnea or other health conditions; it is developed to give you approximate knowledge about sleep apnea so that you can get appropriate consultation. Consulting with a qualified healthcare professional is mandatory to get a definitive diagnosis.



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