Please answer Yes or No to the following questions.

It is important that you answer each question as best you can

Have you been Diagnosed with Obstructive Sleep Apnea (OSA)?

Yes/No

Are you being Treated for Obstructive Sleep Apnea (OSA)?

Yes/No

Are you Compliant with Treatment for Obstructive Sleep Apnea (OSA)?

Yes/No
Symptom
Yes
No

Do You or Have Been Told That You Snore?

Disruptive Sleep (Waking up Multiple Times)

Disturbed or Restless Sleep (Tossing and Turning)

Non-Restorative Sleep (Waking up Tired and Wanting to Sleep Longer)

Have You or Anyone Ever Noticed or Mentioned That You Stop Breathing during Sleep

Frequent Unexpected Awakenings from Sleep

Waking Up Gasping during Sleep

Waking Up Choking during Sleep

Do You Occasionally Fall Asleep or Nod-Off in Situations Where You Did Not Intend To

Excessive Daytime Sleepiness / Tiredness

Waking Up with Dry Mouth

Morning (Waking Up) Headaches

Teeth Grinding (Bruxism) During Sleep

Do You Have (or are being treated for) High Blood Pressure and/or Diabetes

Depression (Daytime Symptoms)*

Irritability / Moodiness (Daytime Symptoms)*

Your Score:

YOUR RISK ASSESSMENT

Note: Answering Yes to either or both questions marked with * increases your risk to the next severity category.

1-3 “Yes” indicates a MILD RISK FOR OSA
4-6 “Yes” indicates a MODERATE RISK FOR OSA
7-10 “Yes” indicates a HIGH RISK FOR OSA
11-14 “Yes” indicates a DANGEROUSLY HIGH RISK
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