11 Sleep Apnea Screening Questionnaire

Sleep Apnea Screening Questionnaire

The Institute for Functional Medicine
Date*

MonthDayYear
Date
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com

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)?*

YesNo
2. Is you snoring loud (can it be heard through a door or a wall)?*

YesNo
3. Has it ever been reported to you that you stop breathing or gasp during sleep?*

NeverOccasionallyFrequently
4. What is your shirt collar size*

Female: Less than 16 inchesFemale: More than 16 inchesMale: Less than 17 inchesMale: More than 17 inches
5a. Do you occasionally fall asleep during the day when you are busy or active?*

YesNo
5b. Do you occasionally fall asleep during the day when you are driving or stopped at a light?*

YesNo
6. Have you had or are you being treated for high blood pressure (hypertension)?*

YesNo
Calculation
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.
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I understand I will receive an email response at the provided email from FunctionalMedicine.MD upon submission of this document with a PDF of the completed agreement attachment. I must use the password "Patient#1" to open the PDF.
Should be Empty: