Sleep Apnea Screening Questionnaire

This short self evaluation will assist your physician in the assessment of your risk for Obstructive Sleep Apnea (OSA). Complete the following questionnaire to identify the possibility of a sleep disorder. If your screening questionnaire suggests you may be at risk for a sleep disorder, you may want to discuss the results with your physician for further evaluation.
( * denotes a required question)

Your information:

SNORING: Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?*

TIRED: Do you often feel tired, fatigued, or sleepy during the daytime? *

OBSERVED: Has anyone observed you stop breathing during your sleep? *

PRESSURE: Do you have or are being treated for high blood pressure? *

BMI: Enter your height and weight to determine if your Body Mass Index is more than 35. *

Your height:

Your weight:

AGE: Are you older than 50? *

NECK SIZE: Do you have a neck that measures more than 16 inches/ 40cm around (measure at Adam's Apple)? *

GENDER: Are you a male? *

Questionnaire adapted from F Chung Anesthesiogy 2008 and F Chung Br J Anaesth 2012.