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: ____/____/________
OFFICE
USE ONLY
Advanced
screening criteria, if yes to any below pt should be scheduled for advanced OSA
screening.
______
ESS Score ≥ 8? _____ Pt. Eval ≥ 2? _____ Subjective Sleep Eval
≥ 3? _____ Prior OSA
Diagnosis ≥ 1?