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No PDF YetQUESTIONNAIRE FOR SLEEP APNEA RISK

Instructions:
Answer each question as accurately as you can. Fill in your name, email address or FAX number and other requested data (optional). This information is only used to communicate results back to you. All names, phone numbers, etc. are purged after their intended use and are not made available to any other organization, commercial entity or individual.

Complete the questionnaire and receive a Report and free information kit with DVD on Sleep Awareness. We will need you to complete those items marked in red in order for you to receive your report & kit.
Questionnaire
Note: Red Items are required


First Name:
M.I.: Last Name:  
Address: City:
State:
Zip:
Home Phone#:  
Fax#: 
Date of Birth: mm/dd/yyyy
Email:
Primary Care Physician’s Name :
Physician's Tel# :
Physician’s Email :
or...Fax# :



Assess your risk for sleep apnea. The total score for the first 4 Questions is your Apnea Risk Score. Complete this questionnaire, select your best answer for each question and see how you score.

Question 1

How frequently do you experience or have you been told about snoring loud enough to disturb the sleep of others?

Rarely (less than once a week)
Occasionally (1 – 3 times a week)
Frequently (More than 3 times a week)

Question 2

How often have you been told that you have "pauses" in breathing or" stop" breathing during sleep?

Rarely (less than once a week)
Occasionally (1 – 3 times a week)
Frequently (More than 3 times a week)

Question 3

How much are you overweight?

Severely (more than40 pounds)

Question 4

What is your Epworth Sleep Scale? Click Here To See Scale

19 or Greater

Question 5

Does your medical history include any one or more of the following conditions?
High Blood Pressure
Stroke
Heart Disease
More than 3 awakenings per night (on the average)
Excessive fatigue
Difficulty concentrating or staying awake during the day



If you answered questions 1-4 and your Risk Score was over 6 , especially if you checked any boxes in question 5, because you have one or more of the conditions identified, then you may be at risk for sleep apnea and should discuss this with your physician. By completing the necessary fields on this survey, SleepWell America.com can automatically forward this to your primary care physician who will be contacting you for a follow up office visit in the next few days, so that you they can discuss with you the need for completing a sleep study.
Note: You should always discuss sleep-related complaints with your physician before deciding on medical evaluation and treatment.

 

PLEASE INDICATE WHICH OF THE FOLLOWING CONDITIONS YOU FEEL YOU MIGHT HAVE:
Excessive Daytime Sleepiness Sleep Disordered Breathing
Snoring Sleep Talking
Insomnia Periodic Limb Movement
Restless Leg Syndrome Sleepwalking
light Sleeper Deep Sleeper
Unable to Arouse



After we receive your information, we will start working on returning to you  a completed report
and free information kit with DVD on Sleep Awareness from SleepWell America.

If you would like to speak to a Representative at Sleep Well America for
further information on contacting a SleepWell America member provider,
please call us at 1- 877- 79 - SLEEP 9am – 6 pm PST.

Click here to download the PDF version of this questionnaire and FAX it to SleepWell America at FAX # 1 -877- 845 - 9355 to receive your report and Information kit with DVD.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The Epworth Sleep Scale

The following questionnaire on the right will help you measure your general level of daytime sleepiness. Answers are rated on a reliable scale called the Epworth Sleepiness Scale (ESS) – the same assessment tool used by sleep experts worldwide.

Each item describes a routine daytime situation. Use the scale below to rate the likelihood that you would doze off or fall asleep (in contrast to just feeling tired) during that activity. If you haven't done some of these things recently, consider how you think they would affect you.

Please note that this scale should not be used to make your own diagnosis. It is intended as a tool to help you identify your own level of daytime sleepiness, which can be a symptom of a sleep disorder.

© Copyright M.W.Johns, 1990. The Epworth Sleepiness Scale is reproduced with permission of Dr. Murray W. Johns.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Epworth Sleep Scale Test
Use the following scale to select a value from 0 to 3 on the drop downs to the right of each of the 8 situations.

0 = no chance of dozing

1 = slight chance of dozing

2 = moderate chance of dozing

3 = high chance of dozing


Situation :
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 to rest 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 traffic
 
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