Sleep Disorder Evaluation

This questionnaire consists of questions to help identify your risk of having sleep apnea. Patients can be classified into High Risk or Low Risk based on your responses to the individual items and their overall scores in the symptom categories. Please fill out this questionnaire to assess your risk for sleep apnea. You will have the option to be contacted by the sleep center at the end of the questionnaire.

Name:
Zip Code: (required)
Email: (required)
Height: feet  inches (required)
Weight: lbs. (required)
Age: (required)
    
1. Do you snore?


 
2. Your snoring is:



 
3. How often do you snore?




 
4. Has your snoring ever bothered other people?



 
5. Has anyone noticed that you quit breathing during your sleep?





 
6. How often do you feel tired or fatigued after you sleep?





 
7. During your waking time, do you feel tired, fatigued or not up to par?





 
8. Have you ever nodded off or fallen asleep while driving a vehicle?


if yes:
10. Do you have high blood pressure?



 
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