Sleep Apnea Screening Form

Patient Name (PRINT) ________________________________________________

Section 1: Epworth Sleepiness Scale

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

(0=never, 1=slight, 2=moderate, 3=high chance of dozing) – CIRCLE ONE RESPONSE FOR EACH QUESTION

Sitting and reading…………………………………………………….  0          1          2          3         

Watching television……………………………………………………  0          1          2          3

Sitting in a public place……………………………………………….. 0          1          2          3

As a passenger in a car for one hour……………………………….. 0          1          2          3

Driving a car stopped for a few minutes in traffic…………………..  0          1          2          3

Sitting & talking to someone…………………………………………. 0          1          2          3

Sitting down quietly after lunch without alcohol…………………… 0          1          2          3

Lying down to rest in the afternoon…………………………………. 0          1          2          3         

Total Score: ______

Section 2: Patient Evaluation

Fill in the blanks, circle one yes or no response for each question

                                                                                                                     No(0)    Yes(1)

BMI (See Attached Chart):          ______  Is it greater than or equal to 30?            0          1

Neck Circumference                  ______  Is it >17” (Men) or >15”(Women)?           0          1

Have you gained at least 15lbs in the past 6 months?                                          0          1

Total Score: ______

Section 3: Subjective Sleep Evaluation

Please circle one yes or no response for each  question                                                         No(0)    Yes(1)

Do you snore?.......................................................................................................... 0          1

You, or your spouse, would consider your snoring louder than a person talking….           0          1

Your snoring occurs almost every night………………………………………………..            0          1

Your snoring is bothersome to your bed partner………………………………….......            0          1

Do you feel that in some way your sleep is not refreshing or restful?.....................           0          1

Do you wake up at night or in the mornings with headaches?................................           0          1

Do you experience fatigue during the day and have difficulty staying awake?.......             0          1

Do you have trouble remembering things or paying attention during the day?.......             0          1

Do you have high blood pressure?.........................................................................        0          1

Total Score: ______

Section 4: Prior Diagnosis

                                                                                                                     No(0)    Yes(1)

Have you previously been diagnosed with sleep apnea?                                     0          1

            If Yes:

            When were you diagnosed? (Approx mo/yr)        ____________

            Were you put on CPAP Therapy for treatment?   ____________

            Are you still using your CPAP every night?         ____________

Total Score: ______

Notes: (Please insert any notes for the doctor regarding snoring, sleep patterns or sleep apnea that you feel may be appropriate use back of page if necessary.)

Patient Signature:___________________________________       Date: ____/____/________