Sleep Questionnaire

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

Based on your “apnea risk score,” we suggest the following:

• 5–9  Discuss concerns with your doctor at your next visit.
• 10–14  Important to discuss concerns with your doctor as soon as possible, and consider a sleep evaluation.
• 15–19  Sleep consultation or sleep study
• > 20  Schedule sleep study, as significant risk for sleep apnea is present.