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Sleep Questions

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  • Sleep Apnea Screening Questions

  • Sleep apnea is a common disorder characterized by repetitive collapse of the pharyngeal airway during sleep leading to oxygen deprivation.

  • Each choice is worth points. The higher the total, the more likely you have sleep apnea. The point amount is in parentheses.

  • Scoring:

    9+ points = High probability

    6-8 points = Moderate probability

    5 or less = Low probability

  • Consequences of untreated sleep apnea include: sleep disruption, waking sleepiness, poor job performance, decreased quality of life, increased motor vehicle accidents, systematic hypertension, mild pulmonary hypertension, arrhythmias, myocardial infarction, stroke.
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  • Epsworth Sleepiness Scale

  • The Epworth Sleepiness Scale (ESS) was developed and validated by Dr. Murray Johns of Melbourne, Australia. It is asimple, self-administered questionnaire that is widely used by sleep professionals in quantifying the level of daytimesleepiness.

    How likely are you to doze off or fall asleep in the following situations, in contrast to feeling ‘just tired’? This refers to yourusual way of life at present and in the recent past. Even if you have not done some of these things recently, try to workout how they would have affected you.

    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

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  • Sleep Apnea/Snoring Questionnaire

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After submitting, feel free to return to the Patient Forms page. Please note, there are multiple forms for each section.


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