* Required Information
Name
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Date
*
Phone
*
Email_Address
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How did you hear about us?
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1. Do you snore or have been told by someone that you snore?
Yes (2pts)
No
2. Has anyone ever noticed that you quit breathing during your sleep?
Yes (3pts)
No
3. Do you ever awaken with a sensation of gasping or choking?
Yes (3pts)
No
4. Do you often feel tired or fatigued immediately after getting up from sleep?
Yes (1pt)
No
5. During your waking time, do you often feel tired, fatigued or not up to par?
Yes (1pt)
No
6. Have you, in the past 6 months, nodded off or fallen asleep in any situations where you did not intend to?
Yes (1pt)
No
7. Do you have (or are being treated for) high blood pressure?
Yes (1pt)
No
Total Points
Please add up the points from question that were answered "yes". If the point total is greater than 2, the patient is a good candidate for a diagnostic sleep study.
0 - 2 = Lower risk of having Obstructive Sleep Apnea
3 - 4 = Moderate risk of having Obstructive Sleep Apnea
5 - 12 = High risk of having Obstructive Sleep Apnea
This questionnaire utilizes portions of the Berlin questionnaire and the Epworth sleepiness scale (ESS), which are widely recognized by the AASM as diagnostic tools for obstructive sleep apnea syndrome (OSAS)
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