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
