• 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:

  • 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.


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    Sleep Apnea/Snoring Questionnaire


  • Adult/Child Sleep & Breathing Questionnaire


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    Adult Sleep & Breathing Questionnaire

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    Pick a Date
  • BMI Formula BMI = (Your weight in Kg) / (Your height in Meters * Your height in Meters)



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    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.

  • 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

  • Negative

  • Positive

  • Category 2

  • Negative

  • Positive

  • Category 3

  • RISK LEVEL: No Risk

  • RISK LEVEL: Low Risk

  • CHILD

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    Pick a Date

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    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

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    Speech Questionnaire


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    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:

  • Negative

  • Positive

  • Clear
  •  -  -
    Pick a Date
  • (Your digital signature (full name) is as legally binding as a physical signature.)

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  • Should be Empty: