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Clinical Screening for OSA

TO BE COMPLETED BY A MEMBER OF THE PROFESSIONAL TEAM DURING AN OFFICE VISIT

Has the Patient been Diagnosed with OSA?

Yes/No

Is the Patient being Treated for OSA?

Yes/No

Is the Patient Compliant with Treatment for OSA?

Yes/No

Does the patient have any of the following (check all that apply):

Snoring

Daytime Tiredness/ Drowsiness/ Sleepiness

Observed Pauses in Breathing During Sleep

Age (> 50 Years)

Gender (Male)

Obesity (BMI>30)

Large Neck Size (Men >17” or Women >16”)

GERD (Acid Refulx)

Diabetes

Enlarged Tonsils

Enlarged Tongue

Narrow Mandible, Retruded Mandible

High Blood Pressure

What does the patient’s airway look like (select one)?

class_1
class_2
class_3
class_4

Your Score:

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* >4 number of positive answers and/or a class III or IV airway make it more likely that the patient has obstructive sleep apnea.

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