Sleep Disorder Assessment

Home Services Sleep Disorder Assessment

The risk factors associated with untreated sleep apnea are too serious to ignore.

Complete the following questionnaire to determine if the condition may be impacting your sleep, health and overall quality of life.

Epworth Sleepiness Scale

How likely are you to doze off while doing the following activities? Please use the following scale:

0 = never, 1 = slight, 2 = moderate, 3 = high.

Part 1

1. Being a passenger in a motor vehicle for an hour or more

2. Sitting and talking to someone

3. Sitting and reading

4. Watching TV

5. Sitting inactive in a public place

6. Lying down to rest in the afternoon

7. Sitting quietly after lunch without alcohol

8. In a car, while stopped for a few minutes in traffic

Part 2

1. Have you been told that you snore?

2. Does your family have a history of premature death?

3. Do you have diabetes?

4. Have you ever been told you have coronary artery disease?

5. Do you have high blood pressure?

6. Have you ever experienced irregular heart rhythms?

Part 3

1. Have you ever been diagnosed with sleep apnea?

2. Do you dream?

3. Do you awaken from sleep with chest pain or shortness of breath?

4. Has anyone said that you seem to stop breathing while sleeping?

5. Have you ever had a stroke?

6. Have you ever been told you have congestive heart failure?

7. Do you have or did you ever have atrial fibrillation?

8. Are you currently taking pain meds?

9. Do you have a CPAP?

10. Do you use a CPAP at least 4 hours every night?

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