Patient Assessment Questionnaire

Category 1

Category 2

Category 3

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Jiva Health Inc.
2182 East St, Concord, CA94520
Phone: 925-685-4224 Fax: 925-685-6997

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REM Sleep Diagnostics Inc.
2601 Nut Tree Road, Suite C, Vacaville, CA 95687
Phone: 707-469-8400 Fax: 707-469-8469

Physician Instructions

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

Scoring Categories:
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:

  • History and Physical – Or office note describing the pertinent history and reason for referral. It helps us understand the patient’s overall health status and the likely impact of any sleep-related problem.
  • Most recent CBC and thyroid Panel or TSH – Sleep disorders commonly accompany anemia, polycythemia, and thyroid dysfunction.
  • Current patient demographic information and a copy of the insurance card.

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.

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