Order Number Patient Name * PART A. Obstruction Sleep Apnea & Health History Have you previously been diagnosed/tested for sleep apnea? * Yes No PART B. Obstruction Sleep Apnea Questionnaire: Do you snore loudly (louder than talking loud enough to be heard through a closed door)? * Yes No Do you oftenfeel tired, fatigued, or sleepy during the daytime? * Yes No Has anyone observed you stop breathing during your sleep? * Yes No Do you have or are you being treated for high blood pressure? * Yes No High Risk of OSA: answering yes to two or more questions. Ask our staff for a “Sleep Apnea Survival Kit”, this kit provides education about the health concerns and treatments for snoring and sleep apnea. A low risk score does not necessarily mean you do not have sleep apnea – concerns about sleep apnea, symptoms and health consequences may always be discussed with your family physician.