Screening Sheet for
Sleep Apnea
Name
Date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Email
example@example.com
Phone
Format: (000) 000-0000.
RISK ASSESSMENT
Obstructive Sleep Apnea (OSA) is a common,
but serious medical condition that can affect
your sleep, health and quality of life.
OSA is dangerous.
It's important to treat OSA if you have it.
If left untreated, OSA sufferers are
at higher risk of:
Heart attack
Stroke
Sleepiness that can lead to work
related accidents and car crashes
Answer the following questions to find out if you are at risk. Your health is important to us!
Type a question
Rows
Yes
No
S
(Snoring) Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?
T
(Tired) Do you often feel tired, fatigued, or sleepy during the day?
O
(Observed) Has anyone observed you stop breathing or gasp during sleep?
P
(Blood Pressure) Have you had, or are you currently, being treated for, high blood pressure?
B
(BMI) Is your BMI (body mass index) greater than 35?
A
(Age) Are you over 50 years old?
N
(Neck Circumference) Is your neck size greater than 17" (male) 16" (female)?
G
(Gender) Are you male?
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Obstructive Sleep Apnea
MEDICAL HISTORY
Please check all that apply:
Medical History
Depression, irritability
Morning headaches
Memory and learning problems
Trouble concentrating
Mood swings, personality changes
Chronic nasal congestion
Family history of snoring or sleep apnea
High blood pressure
Stroke
Heart disease
Atrial fibrillation or other problems with your heart rhythm
Type 2 diabetes
Acid reflux
Decreased sex drive
SLEEP HISTORY
Have you ever had a sleep study or been told to get one?
YES
NO
Have you ever been diagnosed with a sleep disorder?
YES
NO
Do you wake up in the morning feeling unrefreshed?
YES
NO
Are you a restless sleeper?
YES
NO
Do you catch yourself nodding off during the day (at times when you shouldn't be)?
YES
NO
Does your bed partner sleep in another room because of your snoring?
YES
NO
Do you wake up frequently to urinate during the night?
YES
NO
Do you grind your teeth at night?
YES
NO
Have you ever had jaw clicking/pain, tooth sensitivity, or been told you have TMD?
YES
NO
Do you have a dry mouth or a sore throat when you wake up?
YES
NO
Have you ever used a CPAP machine?
YES
NO
Are you currently using a CPAP machine?
YES
NO
If yes, do you use your CPAP less than 5 times per week?
YES
NO
Have you tried CPAP and are looking for other treatment choices?
YES
NO
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Screening for
Obstructive Sleep Apnea
SLEEPINESS SCORE
How likely are you to doze off or fall asleep in the situations described below, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you haven't done some of these things recently, try to work out how they would have affected you.
Use the following scale to choose the most appropriate number for each situation:
0
Would never doze
1
Slight chance of dozing
2
Moderate chance of dozing
3
High chance of dozing
Sitting and Reading
Chance of Dozing (0)
Chance of Dozing (1)
Chance of Dozing (2)
Chance of Dozing (3)
Watching tv
Chance of Dozing (0)
Chance of Dozing (1)
Chance of Dozing (2)
Chance of Dozing (3)
Sitting, inactive in a public place (e.g. a theatre or a meeting)
Chance of Dozing (0)
Chance of Dozing (1)
Chance of Dozing (2)
Chance of Dozing (3)
As a passenger in a car for an hour without a break
Chance of Dozing (0)
Chance of Dozing (1)
Chance of Dozing (2)
Chance of Dozing (3)
Lying down to rest in the afternoon when circumstances permit
Chance of Dozing (0)
Chance of Dozing (1)
Chance of Dozing (2)
Chance of Dozing (3)
Sitting and talking to someone
Chance of Dozing (0)
Chance of Dozing (1)
Chance of Dozing (2)
Chance of Dozing (3)
Sitting quietly after a lunch without alcohol
Chance of Dozing (0)
Chance of Dozing (1)
Chance of Dozing (2)
Chance of Dozing (3)
In a car, while stopped for a few minutes in traffic
Chance of Dozing (0)
Chance of Dozing (1)
Chance of Dozing (2)
Chance of Dozing (3)
Signature
Date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
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