Sleep Apnea Risk Assessment




    Contact (Optional)

    Name

    Phone

    Email

    Sex

    Female

    Male

    Neck Size

    Inches

    Medical Conditions: Have you been diagnosed or treated for any of the following conditions?

    Medical Condition

    Yes

    No

    High Blood Pressure

    Heart Disease

    Diabetes

    Stroke

    Depression

    Sleep Apnea

    Epworth Sleepiness Scale: How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usualy way of life in recent times. Even if you have not done some of those things recently, try to work out how they would have affected you. Use the following scale to mark the most appropriate box for each situation.

    Activity

    Would never doze

    Slight chance of dozing

    Moderate chance of dozing

    High chance of dozing

    Sitting and Reading

    Watching TV

    Sitting, inactive, in a a public place (theater, meeting, etc)

    As a passenter in a car for an hour without break

    Laying down to rest in the afternoon when circumstances permit

    Sitting and talking to someone

    Sitting quietly after lunch without alcohol

    In a car, while stopped for a few minutes in traffic

    Recent History: In the past month:

    Question

    Never

    0-1 times
    week

    1-2 times
    week

    3-4 times
    week

    5-7 times
    week

    Have you snored or been told that you snored?

    Do you wake up choking or gasping?

    Have you been told that you stop breathing in your sleep?

    Do you have problems keeping your legs still at night or need to move them to feel comfortable?

    Risk Score: