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

    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