Online Patient Form

Sleep Questions

Name

First Name Middle Name Last Name

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

a) Do you snore on most nights (more than 3x/wk)?

b) Can your snoring be heard through a door or walls?

2. STOP BREATHING

a) Has it ever been reported that you stop breathing or gasp during sleep?

3. COLLAR SIZE

Your Gender:

a) What is your collar size?

4. BLOOD PRESSURE

a) Have you had or are you being treated for high blood pressure?

5. DAYTIME SLEEPINESS

a) Do you occasionally doze or fall asleep during the day when:

You are not busy or active?

You are driving or stopped at a light?

Total Points

5 points or less	Low probability
6-8 points	Probability
9+ points	High probability

5 points or less	Low probability
6-8 points	Probability
9+ points	High probability

5 points or less	Low probability
6-8 points	Probability
9+ points	High probability

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

1. How long have you been aware of your snoring?

2. Have you been told that you stop breathing while you are asleep?

Yes No

3. Approximately how many times per night do you wake up?

4. Do you have any difficulty falling asleep at night?

Yes No

5. How many hours of sleep per night do you get?

6. Do you most often wake up feeling refreshed?

Yes No

7. Does a small amount of alcohol give you a headache?

Yes No

8. Have you seen other doctors about snoring or apnea?

Yes No

Who:

When:

9. Have you had a sleep lab study?

Yes No

When:

10. Do you have difficulty breathing through your nose?

Yes No

11. Do you know if you have any heart irregularities?

Yes No

12. Do you have high blood pressure?

Yes No

13. Do you have any loss of memory?

Yes No

14. Are you depressed?

Yes No

15. What is your normal bedtime?

16. What is your normal wakeup time?

17. Does your work/sleep schedule change?

Yes No

18. Does pain interfere with your sleep?

Yes No

19. Have you ever fallen asleep behind the wheel?

Yes No

IF YES, how many times?

Adult/Child Sleep & Breathing Questionnaire

Is the patient an Adult or a Child?

Adult Child

Adult Sleep & Breathing Questionnaire

Birthday:

Date

Age

Gender:

Male Femal

Your Weight (Kg):

Your Height in (M):

BMI

BMI Formula BMI = (Your weight in Kg) / (Your height in Meters * Your height in Meters)

Have you ever had a sleep test administered?

Yes No

If yes - when did you have your last sleep test?

Have you been diagnosed with Sleep Apnea?

Yes No

Do you currently use a CPAP or Sleep Appliance for Sleep Apnea?

Yes No

Are you happy with your CPAP or Sleep Appliance?

Yes No

If you are not happy - why?

How often do you get out of bed to use the restroom during the night?

Do you usually wake feeling tired and unrested?

Yes No

Do you habitually snore?

Yes No

Have you been diagnosted with Hypertension/High Blood Pressure?

Yes No

Do you often suffer from waking headaches?

Yes No

Do you regularly experience daytime drowsiness or fatigue?

Yes No

Do you have blocked nasal passages?

Yes No

Has anyone observed you stop breathing during your sleep?

Yes No

Do you ever wake up choking or gasping?

Yes No

Do you grind your teeth while sleeping?

Yes No

Is your neck circumference greater than 40 cm/ 15.75" ?

Yes No

Is your Body Mass Index (BMI) more than 35?

Yes No

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.

Siting and reading

Watching TV

Sitting inactive in public place (like a theater or a meeting)

As a passenger in a car for an hour without a break

Lying down to rest in the afternoon when circumstances permit

Sitting and talking to someone

Sitting quietly after lunch without alcohol

In a car, while stopping for a few minutes in traffic

TOTAL SCORE

From 0-7	It is unlikely that you are abnormally sleepy
From 8-9	You have an average amount of daytime sleepiness
From 10-15	You may be excessively sleepy, depending on the situation. You may want to consider seeking medical attention
From 16-20	You are excessively sleep and should consider seeking medical attention

From 0-7	It is unlikely that you are abnormally sleepy
From 8-9	You have an average amount of daytime sleepiness
From 10-15	You may be excessively sleepy, depending on the situation. You may want to consider seeking medical attention
From 16-20	You are excessively sleep and should consider seeking medical attention

From 0-7	It is unlikely that you are abnormally sleepy
From 8-9	You have an average amount of daytime sleepiness
From 10-15	You may be excessively sleepy, depending on the situation. You may want to consider seeking medical attention
From 16-20	You are excessively sleep and should consider seeking medical attention

From 0-7	It is unlikely that you are abnormally sleepy
From 8-9	You have an average amount of daytime sleepiness
From 10-15	You may be excessively sleepy, depending on the situation. You may want to consider seeking medical attention
From 16-20	You are excessively sleep and should consider seeking medical attention

Berlin Questionnaire© - Sleep Apnea

Please choose the correct response to each question.

Category 1

1. Do you snore?

2. You snoring is:

3. How often do you snore?

4. Has your snoring ever bothered other people?

5. Has anyone noticed that you stop breathing during your sleep?

TOTAL SCORE

Negative

Positive

Category 2

6. How often do you feel tired or fatigued after your sleep?

7. During your waking time, do you feel tired, fatigued or not up to par?

8. Have you ever nodded off or fallen asleep while driving a vehicle?

9. How often does this occur?

TOTAL SCORE

Negative

Positive

Category 3

10. Do you have high blood pressure?

Your BMI (kg/m2):

RISK LEVEL: No Risk

RISK LEVEL: Low Risk

CHILD

Date

Age

Study ID#

Person completing form:

Child’s Weight:

Child’s Height:

Please indicate if your child experiences any of the symptoms below by using this scale to measure the severity of these symptoms.

0	No Occurrence	1	Occures Rarely
2	Occurs 2 to 4 times per week	3	Occurs 5 to 7 times per week

1. Snoring

2. Interrupted snoring where breathing stops

3. Labored, difficult or loud breathing at night

4. Gasping for air while sleeping

5. Mouth breathes while sleeping

6. Mouth breathes during the day

7. Restless sleep

8. Grinds teeth while sleeping

9. Talks in sleep

10. Excessive sweating while sleeping

11. Wakes up at night

12. Wets the bed (currently)

13. History of bedwetting

14. Feels sleepy and/or irritable during the day

15. Headaches

16. Frequent throat infections

17. Allergic symptoms

18. Ear infections

19. Short attention span

20. Trouble Focusing

21. Difficulty listening/often interupts

22. Hyperactive

23. ADD/ADHD

24. Sensory Issues

25. Struggles in math at school

26. Struggles in reading at school

27. Speech problems

28. Avoidance behavior towards food or certain types of food

Speech Questionnaire

To be filled out only if #27 was indicated above Please check all that apply to your child.

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:

Snore more than half the time?

Yes No DK

Always snore?

Yes No DK

Snore loudly?

Yes No DK

Have “heavy” or loud breathing?

Yes No DK

Have trouble breathing, or struggle to breathe?

Yes No DK

2. HAVE YOU EVER SEEN YOUR CHILD STOP BREATHING DURING THE NIGHT?

Yes No DK

3. DOES YOUR CHILD:

Yes No DK

Tend to breathe through the mouth during the day?

Yes No DK

Have a dry mouth on waking up in the morning?

Yes No DK

Occasionally wet the bed?

Yes No DK

4. DOES YOUR CHILD:

Yes No DK

Wake up feeling unrefreshed in the morning?

Yes No DK

Have a problem with sleepiness during the day?

Yes No DK

5. HAS A TEACHER OR OTHER SUPERVISOR COMMENTED THAT YOUR CHILD APPEARS SLEEPY DURING THE DAY?

Yes No DK

6. IS IT HARD TO WAKE YOUR CHILD UP IN THE MORNING?

Yes No DK

7. DOES YOUR CHILD WAKE UP WITH HEADACHES IN THE MORNING?

Yes No DK

8. DID YOUR CHILD STOP GROWING AT A NORMAL RATE AT ANY TIME SINCE BIRTH?

Yes No DK

9. IS YOUR CHILD OVERWEIGHT?

Yes No DK

10. THIS CHILD OFTEN:

Does not seem to listen when spoken to directly

Yes No DK

Has difficulty organizing tasks and activities

Yes No DK

Is easily distracted by extraneous stimuli

Yes No DK

Fidgets with hands or feet or squirms in seat

Yes No DK

Is “on the go” or often acts as if “driven by a motor”

Yes No DK

Interrupts or intrudes on others (eg., butts into conversations or games)

Yes No DK

Probability Of Sleep Disordered Breathing

Negative

Positive

Sleep Disordered Breathing Sub-Scale

Signature *

Clear

Date *

Date

(Your digital signature (full name) is as legally binding as a physical signature.)