SLEEP APNEA QUESTIONNAIRE
Assess your risk for sleep apnea. The total score for all 5 sections is your Apnea Risk Score. Print out this questionnaire, write in your best answer for each question and see where you stand.
A. How frequently do you experience or have you been told about snoring loud enough to disturb the sleep of others?
Never
Rarely (less than once a week)
Occasionally (1 – 3 times a week)
Frequently (More than 3 times a week)
Answer_____
B. How often have you been told that you have “pauses” in breathing or stop breathing during sleep?
Never
Rarely (less than once a week)
Occasionally (1 – 3 times a week)
Frequently (More than 3 times a week)
Answer_____
C. How much are you overweight?
Not at all
Slightly (10 – 20 pounds)
Moderately (20 – 40 pounds)
Severely (More than 40 pounds)
Answer______
D. What is your Epworth Sleepiness Score?
(See Epworth Sleep Test in Menu Above)
Less than 8
9 -13
14 – 18
19 or greater
Answer ______
E. Does your medical history include:
High blood pressure
Stroke
Heart disease
More than 3 awakenings per night (on the average)
Excessive fatigue
Difficulty concentrating or staying awake during the day
Answer ______
** If you answered 3 or 4 for questions A-D, and if you have one or more of the conditions listed in question E, then you may be at risk for sleep apnea and should discuss this with your physician.**
Note: You should always discuss sleep-related complaints with your physician before deciding on medical evaluation and treatment.