Obstructive Sleep Apnea Screening Tool

  • Obstructive Sleep Apnea Screening Tool

    Complete this form to help assess your risk for obstructive sleep apnea. Please answer each question carefully.

  • Patient Information

  • Date of Birth*
     - -

  • Screening Questions

  • Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?*
  • Do you often feel tired, fatigued, or sleepy during the daytime?*
  • Has anyone observed you stop breathing during your sleep?*
  • Do you have or are you being treated for high blood pressure?*
  • Is your Body Mass Index (BMI) greater than 35 kg/m²?*
  • Are you 50 years or older?*
  • Is your neck circumference greater than 40 cm (16 inches)?*
  • Are you male?*

  • Low Risk: 0-2 Intermediate Risk: 3-4 High Risk: 5-8

    If you scored higher than 3, ask your physician, nurse practioner or dentist about home sleep apnea testing!

  • This screening tool is intended for clinical use only and should be interpreted in conjunction with clinical judgment and patient history. Completion of this form does not provide a diagnosis but assists in determining whether further testing may be appropriate.

  • Should be Empty: