• 40% of all Americans report difficulty either falling asleep or staying asleep
  • 1 in 3 Americans have undiagnosed sleep disorders
  • It is estimated that 90% of the population of obstructive sleep apnea has not been diagnosed.
SLEEP APNEA QUESTIONNAIRE

Name

Height
Weight
BMI
Insurance
Neck Size
Age
Home Phone
Cell Phone
Email
Physician
CHECK THE FOLLOWING THAT APPLY:
High Blood Pressure/Hypertension
Frequent Night Time Urination
Depression
Memory Loss

This questionnaire was developed based upon published articles by the American Academy of Sleep Medicine (A.A.S.M.)

Points
Have you been told that you stop breathing while asleep? Yes
No
8
Have you ever fallen asleep or nodded off while driving? Yes
No
6
Do you awaken suddenly with shortness of breath, gasping or with your heart racing? Yes
No
6
Do you feel excessively sleepy during the day? Yes
No
4
Has anyone ever told you that you snore while you are sleeping? Yes
No
4
Have you had weight gain and found it difficult to lose? Yes
No
2
Have you taken medication for or been diagnosed with high blood pressure? Yes
No
2
Do you kick or jerk your legs while sleeping? Yes
No
3
Do you feel burning, tingling, or crawling sensations in your legs while you wake up? Yes
No
3
Do you wake up with headaches during the night or in the morning? Yes
No
3
Do you have trouble falling asleep? Yes
No
4
Do you have trouble staying asleep once you fall asleep? Yes
No
4
Add the points together that you have answered “Yes” = Score & Risk Factor
Low Moderate High Severe
0-7 8-11 12-15 16+
Patient Consent

I hereby consent to the disclosure of my response to the Sleep Apnea Questionnaire for the purpose of assisting in the diagnosis and treatment of a potential sleep disorder. I understand that as a part of this organization’s treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent such disclosure for the permitted uses, including, but not limited to, disclosures via fax. I fully understand and accept the terms to this consent.

Patient Signature
Date