Sleep Apnea Questionnaire - Do YOU have Apnea?

This page last updated on 02/11/03 01:12 AM

Circle the numbers of the comments that apply to you.

1. I have been told that I snore.

2. I sometimes suffer from daytime sleepiness.

3. I have dozed off in church on occasion.

4. If I doze off, I sometimes wake up with a "snort."

5. I have been told that I hold my breath or stop breathing in my sleep.

6. I have high blood pressure.

7. I toss and turn a lot in my sleep.

8. I get up to visit the bathroom more than once a night.

9. I often feel sleepy and struggle to stay alert, especially during afternoon meetings.

10. I sometimes fall asleep while watching TV.

11. I have fallen asleep at a stop light or stop sign.

12. I have actually fallen asleep while driving.

13. I wish I had more energy and less fatigue.

14. My neck measures over 17 inches (males) or over 16 inches (females)

15. I am more than 15 pounds overweight.

16. I seem to be losing my sex drive, or my ability to perform in bed.

17. I sometimes get heartburn in the middle of the night.

18. I frequently wake with a bad taste in my mouth, or a dry mouth and throat.

19. I often get morning headaches.

20. When I cannot wake up from a nightmare, I feel paralyzed and I panic.

21. I suddenly wake up gasping for breath.

22. I sometimes wake up with a pounding or irregular heartbeat.

23. I frequently feel depressed.

24. I feel as if I'm getting old too fast.

25. My friends and family say I'm sometimes grumpy and irritable.

26. I have short term memory problems.

27. I don't feel rested or refreshed, even after 8 or 10 hours of sleep.

28. I sometimes perspire a lot, especially at night.

29. I'm tired all the time.

30. I have great difficulty concentrating.

If you circled 5 or more symptoms, you could have OSA (obstructive sleep apnea). The risks of OSA include heart attacks, strokes, impotence, irregular heartbeat, high blood pressure and heart disease.

Take this form to your doctor. Treatments are available to eliminate apneas and snoring without surgery or drugs, but you must visit a sleep center or clinic to be tested.

Sleep tests are simple and painless, and are covered by most insurance policies. Sleep apnea is a life-threatening condition which kills over 38,000 people each year, according to the National Commission on Sleep Disorders Research (NCSDR).

This questionnaire is the result of collaboration between Kathleen Chittenden, Gwynne Wolin and Dave Hargett, all of whom are patients or lay persons interested in sleep disorders, especially sleep apnea. This questionnaire is intended to raise the awareness level of sleep apnea among the millions of persons who have undiagnosed sleep apnea and to provide a springboard for discussion between those persons and their primary care physicians. If in doubt, or if you need additional information, you may need to be referred to a sleep specialist. There is also a wealth of knowledge available on the Internet or in the newsgroup alt.support.sleep-disorder. You may also want to contact the American Sleep Apnea Association at 202-293-3650.

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