Questionnaire for Sleep Apnea Risk

Assess your risk for sleep apnea. The total score for all 5 sections is your Apnea Risk Score. Print out this questionnaire, write in your best answer for each question and see where you stand.

A. How frequently do you experience or have you been told about snoring loud enough to disturb the sleep of others?

1. Never
2. Rarely (less than once a week)
3. Occasionally (1 – 3 times a week)
4. Frequently (More than 3 times a week)

Answer_____

B. How often have you been told that you have “pauses” in breathing or stop breathing during sleep?

1. Never
2. Rarely (less than once a week)
3. Occasionally (1 – 3 times a week)
4. Frequently (More than 3 times a week)

Answer_____

C. How much are you overweight?

1. Not at all
2. Slightly (10 – 20 pounds)
3. Moderately (20 – 40 pounds)
4. Severely (More than 40 pounds)

Answer_____

D. What is your Epworth Sleepiness Score?

1. Less than 8
2. 9 -13
3. 14 – 18
4. 19 or greater

Answer_____

E. Does your medical history include:

1. High blood pressure
2. Stroke
3. Heart disease
4. More than 3 awakenings per night (on the average)
5. Excessive fatigue
6. Difficulty concentrating or staying awake during the day

Answer_____

If you answered 3) or 4) for questions A-D, especially if you have one or more of the conditions listed in question E, then you may be at risk for sleep apnea.