Patient Information Form

OBSTRUCTIVE SLEEP APNEA (OSA) RISK ASSESSMENT
Did you know that:
- OSA interrupts your ability to lose weight?
- OSA is the single biggest reason spouses don't sleep in the same bed
- OSA causes significant memory loss
- OSA keeps you sleepy through the day
Do you have Obstructive Sleep Apnea? Yes=2 points, Occasionally=1 point, No=0 points
Full Name

First NameLast Name
Phone Number

Area CodePhone Number
1. Do you smoke?
2. Do you drink alcohol close to bedtime?
3. Have you been told you snore?
4. When you get 7 to 8 hours of sleep, are you still fatigued or sleepy during the day?
5. Do you have morning headaches?
6. Are you more than 10% above ideal body weight?
7. Do you get food wedged between your teeth?
8. Do you have difficulty losing weight?
9. Do you have hypertension?
10. Do you have acid reflux?
11. Do you have insomnia?
12. Do you take any antidepressants or sleep aids?
13. Do you have difficulty remembering names?
14. Do you take medications for impotence?
Score total points:

0-4 Unlikely host of Obstructive Sleep Apnea

4-6 Low suspicion

7-9 Moderate suspicion

10+ High suspicion
Should be Empty:

OBSTRUCTIVE SLEEP APNEA (OSA) RISK ASSESSMENT