Take a minute or two to see if you or a loved one may be suffering from Sleep Apnea.


Are you or a loved one at risk from Sleep Apnea? Sleep Apnea is a sleep disorder characterized by repeated episodes of failing to breath during sleep. If left untreated, Sleep Apnea increases your risk for life threatening health conditions including congestive heart failure, stroke, high blood pressure, heart disease, diabetes, obesity, depression, and impotence. Yet 75% of severe Sleep Apnea suffers are never diagnosed.

Answer this questionnaire, and click the “Assess My Risk” button to receive a call from Drake & Voto Family Dentistry office to go over the results.


Name *

Email *

Patient Name (if applicable)

Phone *

A. How frequently do you experience or have you been told about shoring loud enough to disturb the sleep of others?

1. Never2. Rarely (less than once a week)3. Occasionally (1 - 3 times a week)4. Frequently (more than 3 times a week)



B. How often have you been told that you stop breathing during sleep?

1. Never2. Rarely (less than once a week)3. Occasionally (1 - 3 times a week)4. Frequently (more than 3 times a week)



C. How much are you overweight?

1. Not at all2. Slightly (10 - 20 pounds)3. Moderately (20 - 40 pounds)4. Severely (more than 40 pounds)


D. Does your medical history include:

1. High blood pressure2. Stroke3. Heart disease4. More than 3 awakenings per night (on the average)5. Excessive fatigue6. Difficulty concentrating or staying awake during the day


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

1. Sitting and reading

0123

2. Watching television

0123

3. Sitting, inactive in a public place (e.g. theater, meeting)

0123

4. As a passenger in a car for an hour without a break

0123

5. Lying down to rest in the afternoon when circumstances permit

0123

6. Sitting and talking to someone

0123

7. Sitting quietly after lunch without alcohol

0123

8. In a car, while stopped for a few minutes in traffic

0123


Notes/Comments:

Would you like for us to set up a consultation for yourself/partner?

YesNo

Note: You should always discuss sleep-related complaints with your physician before deciding on medical evaluation and treatment.