Do I have OSA?

Do I have OSA?

At Advanced Sleep Treatment, we use the Epworth Sleepiness Scale to determine if you would potentially screen positive on a sleep test for Sleep Apnea. The Epworth Sleepiness Scale is a scale intended to measure daytime sleepiness by use of a very short questionnaire. This can be helpful in diagnosing sleep disorders.

Medical Record Update Form

Patient name:

Primary Physician:

Date:

Phone:

Have you ever been given a CPAP device?

If you have been given a CPAP device, do you use it every night?

Are you comfortable with your CPAP and satisfied with its use?

PART 1: Epworth Sleepiness Scale

How likely, are you to doze off while doing the following activities?
Please use the following scale: O= Never, 1= Slight, 2= Moderate, 3= High. Circle one of the following numbers.

Being a passenger in a motor vehicle for an hour or more.

Sitting and talking to someone

Sitting and reading

Watching TV

Sitting inactive in a public place

Lying down to rest in the afternoon

Sitting quietly after lunch without alcohol

In a car, while stopped for few minutes in traffic

PART 2: Every Yes = 1 diagnostic point.

Have you ever been told you snore?

Do you wake up choking or gasping?

Have you had high blood pressure?

Do you have diabetes?

Have you ever experienced an irregular heart rhythm?

PART 3: Every Yes = 1 diagnostic point.

Does snoring cause any problems at home?

Would you like to fix that? (If yes to above question)

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