Chairside Clinical Checklist
TO BE COMPLETED BY A MEMBER OF THE PROFESSIONAL TEAM DURING AN OFFICE VISIT
Does the patient have any of the following (check all that apply):
Snoring
Daytime Tiredness
Observed Pauses in Breathing During Sleep
Age (> 50 Years)
Gender (Male)
OBESITY (BMI>30)
Large Neck Size (Men >17” or Women >16”)
GERD (ACID REFLUX)
DIABETES
ENLARGED TONSILS
ENLARGED TONGUE
ENLARGED UVULA
HIGH BLOOD PRESSURE
What does the patient’s airway look like (select one)?
