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Snoring Self-Assessment Questionnaire
Snoring Self-Assessment Questionnaire
SECTION 1: Nose Test
Q1. With your mouth closed, try breathing in through one nostril (other pinched). Does your nostril collapse inward?
Yes
No
I’m unsure
Q2. Try propping the nostril open with a cotton bud or matchstick. Is breathing easier?
Yes
No
I’m unsure
Q3. With your mouth closed, breathe in through both nostrils. Can you breathe freely?
Yes
No
I’m unsure
Q4. Do you suffer from nocturnal nasal congestion (allergy, rhinitis, sinusitis, post-nasal drip)?
Yes
No
I’m unsure
Q5. Do you have any physical abnormalities in your nose (enlarged turbinates, polyps, deviated septum)?
Yes
No
I’m unsure
SECTION 2: Mouth Breathing Test
Q6. Open your mouth and make a snoring noise. Now, close your mouth and try to make the same noise. Can you only snore with your mouth open?
Yes
No
I’m unsure
Q7. Do you often wake in the morning with a dry mouth, sore throat, or bad breath?
Yes
No
I’m unsure
Q8. Do you sleep with your mouth open?
Yes
No
I’m unsure
Q9. Does your lower jaw drop down during sleep, causing you to sleep with your mouth wide open?
Yes
No
I’m unsure
Q10. Do you have a beard?
Yes
No
I’m unsure
SECTION 3: Tongue Test
Q11. Stick your tongue out and grip it gently between your teeth. Try to make a snoring noise. Is the snoring noise reduced?
Yes
No
I’m unsure
Q12. Have you or your sleeping partner observed you stopping breathing for short periods during sleep?
Yes
No
I’m unsure
SECTION 4: Lifestyle
Q13. Do you smoke?
Yes
No
Prefer not to say
Q14. Do you regularly consume alcohol?
Yes
No
Prefer not to say
Q15. Are you currently taking any sedating medication?
Yes
No
Prefer not to say
SECTION 5: Additional Information – Nose
Q16. Do you have dry or sensitive skin?
Yes
No
I’m unsure
Q17. Do you suffer from nose bleeds or problems with your mucous membrane?
Yes
No
I’m unsure
Q18. Do you have any allergy associated with adhesives used in medical tapes?
Yes
No
I’m unsure
SECTION 6: Additional Information – Tongue/Jaw/Teeth
Q19. Do you suffer from, or have, any of the following (select all that apply):
Crooked teeth
Crowded teeth
Turned teeth
Deep bite
Bruxism (teeth grinding)
Overbite
None of the above
Q20. Is your shirt collar size greater than 16.5”?
Yes
No
I’m unsure
Q21. Height (cm):
Q22. Weight (kg):
Submit Assessment
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