SLEEP APNEA RISK ANALYSIS
Male Female
COMPLETELY FILL IN ONE CIRCLE FOR EACH QUESTION - ANSWER ALL QUESTIONS
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
0
1
2
3
Frequency
Rarely = 0 - 1 times/week
Sometimes = 1 - 2 times/week
Frequently = 3 - 4 times/week
Almost Always = 5 - 7 times/week
Never
Rarely +1
Sometimes +2
Frequently +3
Almost Always +4
Never
Rarely +1
Sometimes +2
Frequently +3
Almost Always +4
Never
Rarely +1
Sometimes +2
Frequently +3
Almost Always +4
Never
Rarely
Sometimes
Frequently
Almost Always