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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)?

class_1
class_2
class_3
class_4

Your Score:

* >4 number of positive answers and/or a class III or IV airway make it more likely that the patient has obstructive sleep apnea.

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