Sleep Apnea Screening Questions

Were you ever diagnosed with sleep apnea? Yes No

If yes, do you currently use any treatment such as CPAP? Yes No

(If yes to both the above, please skip the rest of the form)

1. Snoring

Do you snore loudly? Yes No

2. Tired during the day

Do you often feel tired, fatigued or sleepy during daytime? Yes No

3. Observed Apneas

Has anyone observe you stopping breathing during your sleep? Yes No

4. Blood Pressure

Do you have or are you being treated for high blood pressure? Yes No

5. Body Mass Index -

BMI more than 35kg/m2? Yes No

(If you do not know, let the doctor fill this for you)

6. Age -

Is your age over 50 years old? Yes No

7. Neck circumference

Is your neck circumference greater than 40 cm? (16’’) Yes No

(If you do not know, let the doctor fill this for you)

8. Gender

Are you male? Yes No

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Key: High risk of sleep apnea if you answered –’ Yes’ to three or more items

Low risk of sleep apnea if you answered – ‘Yes’ to less than three items

Please Fax This Form and a Prescription for any Sleep Studies to Sleep Medical Associates, PLLC

(718) 946-5502 or call us at (718) 946-5500. You can visit www.w8md.com for more information on

weight loss and sleep.