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Berlin Sleep Apnea Quiz
Obstructive Sleep Apnea
Berlin Sleep Apnea Quiz
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Berlin Sleep Apnea Quiz
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Do you snore? Are you tired during the day and lack energy? Do you have high blood pressure? If so, you may be at risk for Obstructive Sleep Apnea (OSA).
By completing the following questions, we can accurately determine whether you are at high risk to be suffering from Obstructive Sleep Apnea.
* Indicates required information
First Name:
*
Last Name:
*
Address:
*
City:
*
State:
*
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
*
Phone:
*
Email Address:
*
Primary Care Physician:
*
Physician's City:
Height:
*
Weight:
*
Age:
*
Have you been diagnosed with obstructive sleep apnea?
*
Yes
No
If so, are you currently being treated?
*
Yes
No
N/A
1. Do you snore?
*
Yes
No
Don't know
2. Your snoring is:
*
Slightly louder than breathing
As loud as talking
Louder than talking
Very loud
N/A
3. How often do you snore?
*
Almost every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or almost never
4. Has your snoring ever bothered other people?
*
Yes
No
Don't know
5. Has anyone noticed that you quit breathing during your sleep?
*
Almost every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or almost never
6. How often do you feel tired or fatigued after you sleep?
*
Almost every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or almost never
7. During your waking time, do you feel tired, fatigued or not up to par?
*
Almost every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or almost never
8. Have you ever nodded off or fallen asleep while driving a vehicle?
*
Yes
No
9. How often does this occur?
*
Almost every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or almost never
10. Do you have high blood pressure?
*
Yes
No
*This questionnaire is a sleep screening tool. By completing this form you authorize Provena Care @ Home to give your primary care physician the results of this evaluation.
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