Stop bang w8md weight loss and sleep centers sleep apnea screening questions
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Transcript of Stop bang w8md weight loss and sleep centers sleep apnea screening questions
Sleep Apnea Screening Questions
Were you ever diagnosed with sleep apnea? Yes No
If yes, do you currently use any treatment such as CPAP? Yes No
(If yes to both the above, please skip the rest of the form)
1. Snoring
Do you snore loudly? Yes No
2. Tired during the day
Do you often feel tired, fatigued or sleepy during daytime? Yes No
3. Observed Apneas
Has anyone observe you stopping breathing during your sleep? Yes No
4. Blood Pressure
Do you have or are you being treated for high blood pressure? Yes No
5. Body Mass Index -
BMI more than 35kg/m2? Yes No
(If you do not know, let the doctor fill this for you)
6. Age -
Is your age over 50 years old? Yes No
7. Neck circumference
Is your neck circumference greater than 40 cm? (16’’) Yes No
(If you do not know, let the doctor fill this for you)
8. Gender
Are you male? Yes No
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Key: High risk of sleep apnea if you answered –’ Yes’ to three or more items
Low risk of sleep apnea if you answered – ‘Yes’ to less than three items
Please Fax This Form and a Prescription for any Sleep Studies to Sleep Medical Associates, PLLC
(718) 946-5502 or call us at (718) 946-5500. You can visit www.w8md.com for more information on
weight loss and sleep.