Sleep Apnea Initial Screening


 

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Section I: Epworth Sleepiness Scale

Please indicate how likely you are to doze off or fall asleep in the following situations:

Situation Likeliness
Sitting and reading Please select an item. Please select a valid item.
Watching television Please select a valid item.
Sitting in a public place Please select a valid item.
As a passenger in a care for one hour Please select a valid item.
Driving a car stopped for a few minutes in traffic Please select a valid item.
Sitting and talking to someone Please select a valid item.
Sitting down quietly after lunch without alcohol Please select a valid item.
Lying down to rest in the afternoon Please select a valid item.

Section II: Patient Evaluation

Height: Please select a valid item. Please select an item. Feet Please select a valid item. Please select an item. Please select a valid item.Please select an item.Please select a valid item. InchesPlease select an item.

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Please select a valid item. Please select an item.Please select a valid item. Please select an item.

Sex: Please select a valid item. Please select an item.

Have you gained at least 15 pounds in the last 6 months? Please select a valid item. Please select an item.

Section III: Subjective Sleep Evaluation

Question Yes/No
Do you snore? Please select an item.
You, or your spouse, would consider your snoring louder than a person talking? Please select an item.
Your snoring occurs almost every night? Please select an item.
Your snoring is bothersome to your bed partner? Please select an item.
Do you feel that in some way your sleep is not refreshing or restful? Please select an item.
Do you wake up at night or in the mornings with headaches? Please select an item.
Do you experience fatigue during the day and have difficulty staying awake? Please select an item.
Do you have trouble remembering things or paying attention during the day? Please select an item.
Do you have high blood pressure? Please select an item.

Section IV: Prior Diagnosis

Have you previously been diagnosed with Sleep Apnea? Please select an item.

If Yes:
When were you diagnosed? (approximate month/year)

Were you put on CPAP Therapy for treatment?

Are you still using your CPAP every night?

Any comments or observations regarding your sleep apnea and/or snoring that you would like to share with the doctor:

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