Sleep Disorder Evaluation

This questionnaire consists of 3 categories related to the 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:	(required)
Phone:	(required)
Email:	(required)
Zip Code:	(required)
Height:	3 4 5 6 7 8 feet  1 2 3 4 5 6 7 8 9 10 11 12 inches (required)
Weight:	lbs. (required)
Age:	(required)
Male     Female
1. Do you snore?
a. Yes b. No c. Don't Know
2. Your snoring is:
a. Slightly louder than breathing b. As loud as talking c. Louder than talking d. Very loud - can be heard in adjacent rooms
3. How often do you snore?
a. Nearly every day b. 3-4 times per week c. 1-2 times per week d. 1-2 times per month e. Never or nearly never
4. Has your snoring ever bothered other people?
a. Yes b. No c. Don't know
5. Has anyone noticed that you quit breathing during your sleep?
a. Nearly every day b. 3-4 times per week c. 1-2 times per week d. 1-2 times per month e. Never or nearly never
6. How often do you feel tired or fatigued after you sleep?
a. Nearly every day b. 3-4 times per week c. 1-2 times per week d. 1-2 times per month e. Never or nearly never
7. During your waking time, do you feel tired, fatigued or not up to par?
a. Nearly every day b. 3-4 times per week c. 1-2 times per week d. 1-2 times per month e. Never or nearly never
8. Have you ever nodded off or fallen asleep while driving a vehicle?
a. Yes b. No
if yes:
9. How often does this occur?
a. Nearly every day b. 3-4 times per week c. 1-2 times per week d. 1-2 times per month e. Never or nearly never
10. Do you have high blood pressure?
a. Yes b. No c. Don't know

Pomona Valley Hospital Medical Center - 1798 N. Garey Avenue - Pomona, CA 91767 - (909) 865-9500 - Contact Us