First, please complete the following information:

First Name
Last Name
Telephone 
Email         

Next, Please answer these four general snoring questions: 

General Snoring Questions
1. Have you been told that you snore?
2. Do you snore in all sleep positions?
3. Can you breathe through your nose?
4. Have your tonsils been removed?

For maximum snoring management, airway obstructions should also be identified and corrected. The following eleven questions will help evaluate whether Obstructive Sleep Apnea is present:

Sleep Apnea Questions
5. Do you snore noisily?
6. Do you feel tired or irritable in the morning?
7. Do you awaken with a headache?
8. Do you stop breathing during sleep and then gasp for breath afterwards?
9. Do you experience restless thrashing during sleep?
10. Do you have problems concentrating for long periods?
11. Does sleep suddenly overcome you or do you doze off unintentionally during the day?
12. Do you doze off while driving?
13. Do you experience excessive night time urination?
14. Do you have problems with decreased libido or impotence?
15. Do you have trouble controlling your weight?

Finally, any professional snoring evaluation must include an assessment of the presence of TMJ disease. The following four question pertain to TMJ, a jaw joint disorder:

TMJ Questions
16. Do you clench or grind your teeth?
17. Do you feel stiffness in the area of your jaw joints?
18. Do you have problems opening your jaw wide in the morning?
19. Does your bite feel off in the morning?

By now, you may be asking yourself, "What is a Jaw Advancement Appliance?" A complete description of this device (also known as an MRD) can be found in Treatment Options on page 3.

If you would like to forward the results of this questionnaire and arrange an evaluation/consultation in our Mission Viejo or  Newport Beach office, then click the "Submit" button below. We will contact you as soon as possible to schedule your appointment. Want to add a comment or question to this quiz before sending it? Just put it in the following text box:

Comments/Questions