Sleep Questions
Sleep Apnea Screening
Sleep apnea is a common disorder characterized by repetitive collapse of the pharyngeal airway during sleep leading to oxygen deprivation.
Each choice is worth points. The higher the total, the more likely you have sleep apnea. The point amount is in parentheses.
1. SNORING
2. STOP BREATHING
3. COLLAR SIZE
4. BLOOD PRESSURE
5. DAYTIME SLEEPINESS
a) Do you occasionally doze or fall asleep during the day when:
Consequences of untreated sleep apnea include: sleep disruption, waking sleepiness, poor job performance, decreased quality of life, increased motor vehicle accidents, systematic hypertension, mild pulmonary hypertension, arrhythmias, myocardial infarction, stroke.
Sleep Apnea/Snoring Questionnaire
Adult/Child Sleep & Breathing Questionnaire
Adult Sleep & Breathing Questionnaire
BMI Formula BMI = (Your weight in Kg) / (Your height in Meters * Your height in Meters)
The Epworth Sleepiness Scale
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have effected you. Use the following scale to choose the most appropriate number for each situation.
Berlin Questionnaire© - Sleep Apnea
Please choose the correct response to each question.
Category 1
Negative
Positive
Category 2
Category 3
RISK LEVEL: No Risk
RISK LEVEL: Low Risk
CHILD
Please indicate if your child experiences any of the symptoms below by using this scale to measure the severity of these symptoms.
Speech Questionnaire
Pediatric Sleep Questionnaire: Sleep-Disordered Breathing Subscale*
Please answer these questions regarding the behavior of your child during sleep and wakefulness. The questions apply to how your child acts in general during the past month, not necessarily during the past few days since these may not have been typical if your child has not been well. You should tick the correct response as Yes, No or Don't Know (DK)
1. WHILE SLEEPING, DOES YOUR CHILD:
10. THIS CHILD OFTEN:
(Your digital signature (full name) is as legally binding as a physical signature.)