This self-assessment questionnaire will help identify
patients at risk for Obstructive Sleep Apnea (OSA) and
those who snore but have a low risk of OSA. To complete and score the questionnaire, follow these instructions:
Step 1: Have the patient complete the questionnaire.
Step 2: Score the questionnaire.
Scoring Questions: Any answer in blue is a positive response
Category 1 is positive, with two or more positive responses to questions 1-5.
Category 2 is positive, with two or more positive responses to questions 6-9.
Category 3 is positive, with one positive response and/or a BMI >30.
Final Result: Two or more positive categories indicates a high likelihood of sleep-disordered breathing.
Step 3: Discuss results with the patient. A patient has a positive questionnaire if they score “positive” in two or more sections. In this case, discuss the patient’s risk of a sleep disorder and explore their willingness to go to a sleep center for additional evaluation and polysomnography.
Thank you in advance for including the following information:
We appreciate your referral and will send you a consultation report, as well as reports for any testing and follow-up visits.
REM Sleep Diagnostics follows strict and proven guidelines established by the American Academy of Sleep Medicine, ensuring every patient has the most thorough, safe, and accurate sleep evaluation possible. We are proud to provide custom-tailored solutions to manage your patients’ sleep disorders effectively so they can enjoy a lifetime of better rest and better health.