SLEEP APNEA SELF ASSESSEMENT QUESTIONNAIRE
1. Do you experience any of these problems?
- Daytime sleepiness
- Unrefreshing sleep
- Tiredness and Fatigue
- Insomnia
2. Have you ever woken up from sleep with a choking sound or gasping for breath?
- Yes
- No
3. Has your spouse/ partner noticed that you snore or stop breathing while you sleep?
- Yes
- No
4. Have you ever had any of these other symptoms?
- Nocturia (waking during the night to go to the bathroom)
- Morning headaches
- Difficulty concentrating
- Memory loss
- Decreased sexual desire
- Irritability
5. Do you have any of these physical features?
- Obesity - body mass index (BMI) of 30 or higher
- Large neck size - 17 inches or more for men, 16 inches or more for women
- Enlarged tongue or tonsils
- Recessed jaw
- Nasal polyps or deviated septum
6. Do you have any of these other medical problems that are common in people with sleep apnea?
- High blood pressure
- Mood disorders
- Coronary artery disease
- Stroke
- Congestive heart failure
- Heart attack
- Atrial fibrillation
- Type 2 diabetes
If you answered YES to any of these questions, you may have Sleep Apnea. Please consult your doctor for an assessment and referral to a sleep specialist.