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: