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Questionnaire for Sleep Apnea Risk

Assess your risk for sleep apnea. The total score for all 5 sections is your Apnea Risk Score. Write in your best answer for each question and see where you stand.

If you so desire, you may print this quesitonnaire to fill in your answers and see where you stand. Click here to access the pdf version of the questionnaire for easy printing.

A. How frequently do you experience or have you been told about snoring loud enough to disturb the sleep of others?

1. Never
2. Rarely (less than once a week)
3. Occasionally (1-3 times a week)
4. 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?

1. Never
2. Rarely (less than once a week)
3. Occasionally (1-3 times a week)
4. Frequently (More than 3 times a week)

Answer_____

C. How much are you overweight?

1. Not at all
2. Slightly (10 – 20 pounds)
3. Moderately (20 – 40 pounds)
4. Severely (More than 40 pounds)

Answer_____

D. What is you Epworth Sleepiness Score?

1. Less than 8
2. 9 - 13
3. 14 -18
4. 19 or greater

Answer_____

E. Does you medical history include:

1. High blood pressure
2. Stroke
3. Heart disease
4. More than 3 awakenings per night (on the average)
5. Excessive fatigue
6. Difficulty concentrating or staying awake during the day

Answer_____

If you answered 3 or 4 for question A-D, especially 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.

 

For more information or to receive a referral to the Palomar Health Sleep Lab, call 760.739.3685.