OBSTRUCTIVE SLEEP APNEA RISK ASSESSMENT

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SLEEP SCREENING

SLEEP SCREENING

WHAT IS YOUR RISK LEVEL FOR SLEEP APNEA? please fill out and submit this form to find out 561-702-0039

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1
SLEEP SCREENING QUESTIONAIRE More than a million Americans suffer from Obstructive Sleep Apnea (OSA). Despite this high prevalence, 93% of women and 82% of men with moderate to severe OSA remain UNDIAGNOSED and UNAWARE that they have deadly disease. Please complete this short questionnaire to determine your risk of OSA. Your information is confidential and will only be shared with healthcare providers for diagnostic and treatment purposes.
First Name
Last Name
2
Phone Number
Area Code
Phone Number
3
Do you snore loudly or have you been told you snore loudly?
YES
NO
4
Do you experience daytime sleepiness or drowsiness or fatigue driving ?
YES
NO
5
Have you ever stopped breathing while sleeping or been observed choking/ gasping for air while sleeping?
YES
NO
6
Have you been treated for high blood pressure?
YES
NO
7
Age> 50
YES
NO
8
Do you wake up 2-3 times a night?
YES
NO
9
Have you been recommended a Night Guard?
YES
NO
10
Are your tonsils enlarged?
YES
NO
11
Male?
YES
NO
12
LOW RISK=0-2 MEDIUM RISK=3-4 HIGH RISK= 5-8
13
SHARE OUR WEBSITE AND SAVE A LIFE!NON-CPAP TREATMENT FOR OBSTRUCTIVE SLEEP APNEA
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