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)
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Answer_____
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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)
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Answer_____
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C. How much are you overweight?
Not at all
Slightly (10 – 20 pounds)
Moderately (20 – 40 pounds)
Severely (More than 40 pounds)
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Answer______
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D. What is your Epworth Sleepiness Score?
(See Epworth Sleep Test in Menu Above)
Less than 8
9 -13
14 – 18
19 or greater
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Answer ______
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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
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Answer ______
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** 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.**
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Note: You should always discuss sleep-related complaints with your physician before deciding on medical evaluation and treatment.