|
Use this brief survey to assess your risk for sleep apnea. The total score of all give sections denotes your "Apnea Risk Score."
1. Do you have a history of snoring?
a. No (0)
b. Mild / infrequent (0)
c. Moderate / inconsistent (2)
d. Severe / consistent (8)
2. Have you ever been told that you have "pauses" in breathing during sleep?
a. No (0)
b. Yes, but infrequent (2)
c. Yes, inconsistent but most nights (8)
d. Yes, severely so (10)
3. Are you overweight?
a. No (0)
b. Yes, but by less than 20 lbs (2)
c. Yes, by 20 - 50 lbs (3)
d. Yes, more than 50 lbs (8)
4. Evaluate your levels of sleepiness
a. Would never doze (0)
b. Have a slight chance of dozing (1)
c. Have a moderate chance of dozing (6)
d. Have a high chance of dozing (8)
5. Does your medical history include?
a. High blood pressure (6)
b. Stroke (1)
c. Heart Disease (1)
d. Morning Headaches (1)
e. 3+ awakenings per night (4)
f. Excessive fatigue (1)
g. Depression (1)
h. Diabetes of any level (1)
TOTAL Apnea Risk Score
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you.
The Epworth Sleepiness Scale is used to help you identify your own level of day time sleepiness. Use the following scale to choose the most appropriate number for each situation:
0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
_____ Sitting and reading
_____ Watching TV
_____ Sitting, inactive in a public place (e.g. a theater or a meeting)
_____ As a passenger in a car for an hour without a break
_____ Lying down in the afternoon when circumstances permit
_____ Sitting and talking to someone
_____ Sitting quietly after a lunch without alcohol
_____ In a car, while stopped for a few minutes in the traffic
|
