Are you at risk for sleep apnea?

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.

YOUR RESPONSES SUGGEST YOU MAY HAVE SLEEP APNEA - SEE BELOW:

Based on your answers to the Sleep Questionnaire you may have Sleep Apnea. Sleep apnea is a condition which impairs your breathing and may cause low oxygen levels during sleep.

If you wish further medical evaluation please contact your physician or the Pomona Valley Hospital Sleep Disorders Center. 909-865-9152



You should not consider the results of this questionnaire to mean that you definitely have Sleep Apnea. Further medical evaluation is necessary before diagnosing or excluding Sleep Apnea.

Sleep Apnea may be associated with an increased risk of:

  • High Blood Pressure
  • Heart disease
  • Diabetes
  • Memory impairment
  • Excessive sleepiness
  • Depression

If you wish further medical evaluation please contact your physician or the Pomona Valley Hospital Sleep Disorders Center.

YOUR RESPONSES DO NOT SUGGEST SLEEP APNEA - SEE BELOW:

Sleep Apnea is a condition which causes impairment of breathing during sleep. It is often, but not always associated with snoring.

Your answers to the Sleep Apnea Questionnaire are not suggestive of Sleep Apnea. Sleep Apnea is only one of many conditions which can impair sleep.

You should be aware that the questionnaire you completed does not assure that you do not have Sleep Apnea or another Sleep disorder.

Please contact your physician or the Pomona Valley Hospital Sleep Disorders Center for further help if you feel you have a Sleep problem. 909-865-9152

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