CURRENT THERAPIES Have you attempted CPAP therapy? YesNo If yes, are you able to use it at least 5 nights a week (4 or more hours per night) ? YesNo Have you undergone any surgical attempts to correct your sleep apnea? YesNo Would you prefer an oral device? YesNo Have you tried any ofthe following conservative methods of improving your sleep breathing? (Please check) Weight lossPositional therapy: Avoiding sleeping on your back during sleep (the supine position)Abstaining from the use of alcohol and/or sedatives before bedtime Have you ever been told you stop breathing while asleep? YesNo Have you ever fallen alseep or nodded off while driving? YesNo PATIENT SLEEPINESS SCALE Have you ever woken up suddenly with shortness of breath, gasping or with your heart racing? YesNo Do you feel excessively sleepy during the day? YesNo Do you snore or have you ever been told that you snore? YesNo Have you had weight gain and found it difficult to lose? YesNo Have you taken medication for, or been diagnosed with high blood pressure? YesNo Do you kick or jerk your legs while sleeping? YesNo Do you feel burning, tingling or crawling sensations in your legs when you wake up? YesNo Do you wake up with headaches during the night or in the morning? YesNo Do you have trouble falling alseep? YesNo Do you have trouble staying asleep once you fall asleep? YesNo Name Phone Email get information from us via email YesNo YOUR RISK ASSESSMENT Note: Answering Yes to either or both questions marked with * increases your risk to the next severity category. 1-2 “Yes” indicates a MILD RISK FOR OSA 5-7 “Yes” indicates a HIGH RISK FOR OSA 3-4 “Yes” indicates a MODERATE RISK FOR OSA 8-11 “Yes” indicates a DANGEROUSLY HIGH RISK Δ
