Date

Name (required)

Age (required)

Weight (required)

Phone

Email

Do you snore or have been told by someone that you snore? (required)
---YES - 2 pointsNO

Has anyone ever noticed that you quit breathing during your sleep? (required)
---YES - 3 pointsNO

Do you ever awaken with a sensation of gasping or choking? (required)
---YES - 3 pointsNO

Do you often feel tired or fatigued immediately after getting up from sleep?(required)
---YES - 1 pointNO

During your waking time, do you often feel tired, fatigued or not up to par?(required)
---YES - 1 pointNO

Have you, in the past 6 months, nodded off or fallen asleep in any situation(s) where you did not intend to?(required)
---YES - 1 pointNO

Do you have (or are being treated for) high blood pressure? (required)
---YES - 1 pointNO

Total Points:

Please add up the points from the questionnaire that were answered 'Yes" If the point total is greater than 2, the patient is a good candidate for a diagnostic sleep study.

0-2 = Lower risk of having Obstructive Sleep Apnea
3-4 = Moderate risk of having Obstructive Sleep Apnea
5-12 = High risk of having Obstructive Sleep Apnea