Patient Name:
Date:

Is it possible that you have Obstructive Sleep Apnea (OSA)

Please answer the following questions to determine if you might be at risk.


Snoring?
Do you snore Loudly (loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night)?
Tired?
Do you often feel Tired, Fatigued, or Sleepy during the daytime (such as falling asleep during driving or talking to someone)?
Observed?
Has anyone observed you Stop Breathing or Choking/Gasping during your sleep?
Pressure?
Do you have or are being treated for High Blood Pressure?
Body Mass Index Calculator?
•cm / kg •inches/lb
Height:
Weight:
Calculate BMI:
Body Mass Index more than 35 kg/m²?
Age older than 50?
Date: 
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