Form

Sleep Apnea Questionnaire

First Name

Last Name

Date Of Birth

Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations during your usual way or life recently?

0 = never doze or sleep

1 = slight chance of dozing or sleeping

2 = moderate chance or dozing or sleeping

3 = hight chance of dozing or sleeping

Sitting and reading

Watching TV

Sitting inactive in a public place

Being a passenger in a motor vehicle for an hour or more

Lying down in the afternoon

Sitting and talking to someone

Sitting quietly after lunch ( no alcohol )

Stopped for a few minutes in traffic while driving

Total Score

Obstructive Sleep Apnea History

Do you fall asleep during the day?

Do you suffer from daytime fatigue?

Do you fall asleep while driving?

Has anyone noticed that you stop breathing during sleep?

Do you snore at night?

Do you have disrupted sleep?

Do you urinate more then once during the night?

Do you drink alcoholic beverages?

Do you take sedative type medications?

Do you have high blood pressure?

Do you have an irregular heartbeat?

Have you ever received medical or dental consultation for your sleep apnea?

Did you ever undergo a sleep study? If YES, the severity of your sleep apnea is

What professionals have you seen you for your sleep apnea?

What type of treatment have you tried for your sleep apnea?

Other

Do you understand the long-term complications from untreated sleep apnea?

Patient/Legal Guardian Signature

Date