• Sleep Apnea Screening Questionnaire

    The Institute for Functional Medicine
  • Date*
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  • Date of Birth*
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  • Interpreting your responses

      Your score: {calculation}
      9 points or more: A high probability of a sleep apnea. Refer to sleep specialist or order sleep study.
      6-8 points: Possible sleep apnea, use clinical judgement.
      5 points or less: Low probability of sleep apnea. 

     

  • The following questionnaire is a self-administered screening tool consisting of five simple yes or no questions that was developed by sleep expert, David P. White, M.D., Professor of Sleep Medicine at Harvard Medical School. This brief quiz helps determine the chances of having a sleep-related medical issue and whether further assessment may be warranted.

  • 1. Do you snore on most nights (more than three nights per week)?*
  • 2. Is you snoring loud (can it be heard through a door or a wall)?*
  • 3. Has it ever been reported to you that you stop breathing or gasp during sleep?*
  • 4. What is your shirt collar size*
  • 5a. Do you occasionally fall asleep during the day when you are busy or active?*
  • 5b. Do you occasionally fall asleep during the day when you are driving or stopped at a light?*
  • 6. Have you had or are you being treated for high blood pressure (hypertension)?*

  • Interpreting your responses
    9 points or more: A high probability of a sleep apnea.
    6-8 points: Possible sleep apnea.
    5 points or less: Low probability of sleep apnea.

  • Should be Empty: