Sleep Apnea Screening Questionnaire

Is It Possible That You Have…
Obstructive Sleep Apnea (OSA)?

Please answer the following questions below to determine if you might be at risk.

• Yes

  No

  Not sure

  Snoring: Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?

• Yes

  No

  Not sure

  Tired: Do you often feel tired, fatigued, or sleepy during daytime?

• Yes

  No

  Not sure

  Observed: Has anyone observed you stop breathing during your sleep?

• Yes

  No

  Not sure

  Blood Pressure: Do you have or are you being treated for high blood pressure?

• Yes

  No

  Not sure

  BMI: BMI more than 35?

Body Mass Index Calculator
Metric (centimeters/kilograms)
US (inches/pounds)
Height
Weight
Calculate
BMI
• Yes

  No

  Age over 50 years old?

• Yes

  No

  Gender Male?

• Yes

  No

  Not sure

  Neck circumference is 16 inches or greater?