Sleep Apnea Risk Assessment
Help identify your risk for sleep apnea by answering the following questions. Your responses are confidential and will assist in your health evaluation.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Age
*
Gender
*
Male
Female
Other / Prefer not to say
Height (cm)
*
Weight (kg)
*
Neck circumference (cm)
*
Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?
*
Yes
No
Not sure
Has anyone observed you stop breathing during your sleep?
*
Yes
No
Not sure
How often do you experience the following symptoms?
*
Rows
Never
Rarely
Sometimes
Often
Always
Daytime sleepiness
1
2
3
4
5
Morning headaches
6
7
8
9
10
Difficulty concentrating
11
12
13
14
15
Waking up with dry mouth or sore throat
16
17
18
19
20
Do you have or have you ever been diagnosed with any of the following conditions? (Select all that apply)
*
High blood pressure (hypertension)
Diabetes
Heart disease
None of the above
Other
On a scale of 1 to 5, how likely are you to doze off or fall asleep during the following situations? (1 = Never, 5 = Very likely)
*
Rows
1
2
3
4
5
Sitting and reading
21
22
23
24
25
Watching TV
26
27
28
29
30
Sitting inactive in a public place (e.g., theater, meeting)
31
32
33
34
35
As a passenger in a car for an hour without a break
36
37
38
39
40
Please provide any additional comments or information relevant to your sleep or health.
Submit Assessment
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