Dr. Darrell Morden

1107-37th St. SW Calgary, AB T3C 1S5

(403) 242-5777

Screening Sheet for Sleep Apnea


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RISK ASSESSMENT

Obstructive Sleep Apnea (OSA) is a common, but serious medical condition that can affect your sleep, health and quality of life.

OSA is dangerous.
It's important to treat OSA if you have it.

If left untreated, OSA sufferers are at higher risk of:

  • Heart attack
  • Stroke
  • Sleepiness that can lead to work related accidents and car crashes


Answer the following questions to find out if you are at risk. Your health is important to us!

S Snoring Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?
T Tired Do you often feel tired, fatigued, or sleepy during the day?
O Observed Has anyone observed you stop breathing or gasp during sleep?
P Blood Pressure Have you had, or are you currently being treated for, high blood pressure?
B BMI Is your BMI (body mass index) greater than 35?
A Age Are you over 50 years old?
N Neck Circumference Is your neck size greater than 17" (male) 16" (female)?
G Gender Are you male?

MEDICAL HISTORY


   Please check all that apply:

SLEEP HISTORY

Have you ever had a sleep study or been told to get one?
Have you ever been diagnosed with a sleep disorder?
Do you wake up in the morning feeling unrefreshed?
Are you a restless sleeper?
Do you catch yourself nodding off during the day (at times when you shouldn't be)?
Does your bed partner sleep in another room because of your snoring?
Do you wake up frequently to urinate during the night?
Do you grind your teeth at night?
Have you ever had jaw clicking/pain, tooth sensitivity, or been told you have TMD?
Do you have a dry mouth or a sore throat when you wake up?
Have you ever used a CPAP machine?
Are you currently using a CPAP machine?
If yes, do you use your CPAP less than 5 times per week?
Have you tried CPAP and are looking for other treatment choices?

SLEEPINESS SCORE

How likely are you to doze off or fall asleep in the situations described below, in contrast to feeling just tired? This refers to your usual way of life in recent times.

Even if you haven't done some of these things recently, try to work out how they would have affected you.

Use the following scale to choose the most appropriate number for each situation:

0   Would never doze
1   Slight chance of dozing
2   Moderate chance of dozing
3   High chance of dozing

Situation Chance of Dozing
Sitting and reading 0 1 2 3
Watching TV 0 1 2 3
Sitting, inactive in a public place (e.g. a theatre or a meeting) 0 1 2 3
As a passenger in a car for an hour without a break 0 1 2 3
Lying down to rest in the afternoon when circumstances permit 0 1 2 3
Sitting and talking to someone 0 1 2 3
Sitting quietly after a lunch without alcohol 0 1 2 3
In a car, while stopped for a few minutes in traffic 0 1 2 3

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