Sleep Apnea Screening Questionnaire

Name*

First Last

Do you snore loudly?*

Do you often feel tired/fatigued, or sleepy during the day?*

Has anyone observed you stop breathing during sleep?*

Are you over 50 years of age?*

What was your gender at birth?*

Is your neck circumference bigger than 17 inches?*

Is your neck circumference bigger than 16 inches?*

What is your BMI (Body Mass Index)?

Use this formula to calculate: weight (lb) / [height (in)]2 x 703

Use the scoring below to determine your risk of OSA

Comments

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