OBSTRUCTIVE SLEEP APNEA RISK ASSESSMENT

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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

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