Sleep Apnea Assessment Form

Kigo Dental - Self Assessment form for sleep apnea

The following is a self-assessment to help you identify factors that may indicate you / your child have sleep apnea. The assessment is meant to be informative but does not substitute for a comprehensive evaluation by your dentist or healthcare provider to determine your actual risk and condition.

Sleep apnea

Be sure to answer all the questions honestly to obtain an accurate score. Hereafter "you" can be related to you, your child, or any person in need of taking this test.

1. Do you experience or have you ever been told that you snore loudly, stop breathing, choke or gasp during sleep?
Yes No

2. Do you wake up with a headache, dry mouth or sore throat in the morning? Do you wake up abruptly with a problem?
Yes No

3. Do you experience difficulty falling or staying asleep?
Yes No

4. Have you ever fallen asleep during the day, such as during a meeting or while driving?
Yes No

5. Do you experience any of the following symptoms during sleep:

A. Pauses in breathing
B. Restless sleep
C. Sweating heavily
D. Teeth grinding or clenching
E. Sleepwalking or sleeptalking
F. Bedwetting
G. Sleep in unusual positions with your head tilted back and neck extended
H. Shortness of breath, choking or gasping of breath
Yes No

6. Do you have a body mass index (BMI) over 30?
Yes No

7. Do you have a neck circumference greater than 17 inches (for men) or 16 inches (for women)?
Yes No

8. Do you have a family history of sleep apnea?
Yes No

9. Do you wake up feeling tired or dizzy or experienced excessive daytime sleepiness or fatigue, even after getting enough sleep?
Yes No

10. Have you noticed any changes in your facial structure, such as a receding chin or forward head posture?
Yes No

11. Do you experience problems with attention or concentration, or do you experience memory impairment frequently?
Yes No

12. Do you experience mood changes, irritability, behavioural problems, or reduced motivation / energy associated with any of the other symptoms?
Yes No

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Note: Please note that this self-assessment form does not intend to provide a definitive diagnosis if you / your child have sleep apnea or other health conditions; it is developed to give you approximate knowledge about sleep apnea so that you can get appropriate consultation. Consulting with a qualified healthcare professional is mandatory to get a definitive diagnosis.

Sleep Apnea Assessment Form

Kigo Dental - Self Assessment form for sleep apnea

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