Screening for Obstructive Sleep Apnea

*Please complete all required items.

 

Answer the following questions to find out if you are at risk for Obstructive Sleep Apnea.

Your Name:* 

 

Date of Birth:* 

 

Email Address:* 

 

S
(Snoring)
  Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?  

 Yes

 No

         
T
(Tired)
  Do you often feel tired, fatigued, or sleepy during the daytime?  

 Yes

 No

         
O
(Observed)
  Has anyone observed you stop breathing during your sleep?  

 Yes

 No

         
P
(Blood Pressure)
  Do you have or are you being treated for high blood pressure?  

 Yes

 No

 

B
(BMI)
  BMI more than 35 kg/m?  

 Yes

 No

         
A
(Age)
  Age over 50 year old?  

 Yes

 No

         
N
(Neck Circumference)
  Neck circumference greater than 40 cm (16 in)?  

 Yes

 No

         
G
(Gender)
  Gender male?  

 Yes

 No

Questions Answered:    Yes Answers: 

 

High risk of OSA: answering YES to three or more items

Low risk of OSA: answering YES to less than three items