By far the number one sleep disorder is Obstructive Sleep Apnea Syndrome (OSA). This condition afflicts many people. Chances are you or someone you know has Obstructive Sleep Apnea Syndrome.

The following is a questionnaire that can help your physician determine if you need to be evaluated in a sleep laboratory.

Once you have provided your information, click on the button to format this page for printing.


Sleep Evaluation
Obstructive Sleep Apnea Syndrome
   
       
Patient Name:
Date of Birth:
Height:
Weight:
Male/Female: 
   
 
1:) 
Do you snore?    
 
Yes
No
Don't Know
   
       
2:) 
If you snore: Your snoring is?
 

Slightly louder that breathing?
As loud as talking.
Louder than talking.
Very Loud. Can be heard in adjacent rooms.

 
3:)
How often do you snore?
  Nearly every day.
3-4 times per week.
1-2 times per week.
1-2 times per month.
Never or nearly never.
   
4:) 
Has your snoring ever bothered people?
  Yes
No
   
5:) 
Has anyone every noticed you stop breathing during sleep?
  Nearly every day.
3-4 times per week.
1-2 times per week.
1-2 times per month.
Never or nearly never.
   
6:) 
Do you awaken with the anxiety, racing heartbeat, or with a gasp?
  Yes
No
   
7:) 
Do you have a headache when you wake up in the morning?
Nearly every day.
3-4 times per week.
1-2 times per week.
1-2 times per month.
Never or nearly never.
 
8:) 
How often do you feel tired or fatigued after your sleep?
Nearly every day.
3-4 times per week.
1-2 times per week.
1-2 times per month.
Never or nearly never.
 
9:) 
During your wake-time, do you feel tired, fatigued or not up to par?
Nearly every day.
3-4 times per week.
1-2 times per week.
1-2 times per month.
Never or nearly never.
 
10:) 
Do you nap during the day?
Yes
No
 
11:) 
Have you ever nodded off or fallen asleep while driving a vehicle?
Yes
No
 
12:) 
If yes, how often does it occur?
Nearly every day.
3-4 times per week.
1-2 times per week.
1-2 times per month.
Never or nearly never.
 
13:) 
Do you have high blood pressure?
Yes
No
Don't Know