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Screen for Obstructive Sleep Apnea


Patient Name: Age: D.O.B. Date:

Phone Number: Height: Weight:
Section A. Situation Chance of Dozing

Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations. Please answer the following based on this scale:
0 = Would never fall asleep 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozing

Reading Passenger in a car for 1 hour w/o a break
Watching TV During quiet time after lunch w/o alcohol
Sitting in a public place (Theater/meeting) Lying down to rest when circumstances permit
Driving in a car stopped at a traffic light Sitting and talking with someone
Total Points *0-7 (Normal) = 0   8-9 (Mild) = 1   10-15 (Moderate) = 3   >15 (Significant Risk) = 4
Section A. Risk Points

Section B. Clinical Questions
Has anyone ever told you that you snore? Yes No Do you have heart disease? Yes No
Does your snoring bother anyone? Yes No Do you have high blood pressure? Yes No
Have you ever been told that you stop breathing
while you sleep? 		Yes No Do you have diabetes? Yes No
Do you awake gasping, choking or short of breath? Yes No Do you notice a decreased ability to think clearly? Yes No
Do you have trouble getting out of bed in the morning even though you got enough sleep? Yes No Did you have a stroke? Yes No
Do you have morning headaches? Yes No Are you overweight? Yes No
Are you always tired? Yes No Is your neck size >= 16.5 male >=15.0 female Yes No
Section B. Risk Points
sleepwise
Risk Points Total A+B
Risk for OSA: 0-2 (Low) 3-4 (Moderate) 5-8 (High) 9-18 (Very High)
Diagnostic Sleep Study (PSG) 95810, followed by another night for CPAP titration study if positive for sleep apnea 95811.

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Doctor’s Signature Contact Person’s Name

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Doctor’s Name Printed Telephone No. Ext. Fax No.
Fax this form signed by your doctor with:

  • Demographic information
  • Copy of current insurance information
  • Clinical notes (required for Medicare)

OFFICE PHONE: 702-990-7660 FAX NUMBER: 702-990-7665