SLEEP APNEA QUESTIONNAIRE: Do you have apnea?

I have been told that I snore loudly and irregularly Yes    No

I often suffer from daytime sleepiness Yes    No

If I doze off, I sometimes wake up with a 'snort' or 'gasp' Yes    No

I have been told that I hold my breath or stop breathing in my sleep Yes    No

I toss and turn in my sleep Yes    No

I have high blood pressure Yes    No

I get up to visit the bathroom more than once a night Yes    No

I often feel sleepy and struggle to stay alert, especially during afternoon meetings Yes    No

I often fall asleep while watching TV Yes    No

I have fallen asleep at a stop light or stop sign Yes    No

I have actually fallen asleep while driving Yes    No

I wish I had more energy and less fatigue Yes    No

My neck measures over 17 inches (male) or 16 inches (female) Yes    No

I suddenly wake up gasping for breath Yes   No

I sometimes get heartburn in the middle of the night Yes    No

When I cannot wake up from a nightmare, I feel paralyzed and I panic Yes    No

I frequently feel depressed Yes    No

I feel as if I'm getting old too fast Yes    No

My friends and family say I'm often grumpy and irritable Yes   No

I don't feel rested or refreshed, even after 8 or 10 hours sleep Yes    No

I have great difficulty concentrating Yes    No

I am more than 30 pounds over my ideal weight (or uncontrollable weight gain) Yes    No

I often get morning headaches Yes    No

I seem to be losing my sex drive, or my ability to perform in bed Yes    No

I am tired all the time Yes    No

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If you checked 5 or more symptoms...you could have Obstructive Sleep Apnea (OSA)
Please click here to download the Epworth Sleepiness Scale. Fill this out and bring into the office during your consultation.