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Sleep Apnea Form


 

Think you might have Sleep Apnea?
First you should fill out an Epworth Sleepiness Scale (ESS) form.

Your score will determine if you have mild, moderate or severe sleep apnea.
0 = no chance of dozing
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

SITUATION

CHANCE OF DOZING

Sitting and reading

_______

Watching TV

_______

Sitting inactive in a public place (e.g. a theater or a meeting)

_______

As a passenger in a car for an hour without a break

_______

Lying down to rest in the afternoon when circumstances permit

_______

Sitting and talking to someone

_______

Sitting quietly after a lunch without alcohol

_______

In a car, while stopped for a few minutes in traffic

_______

 

TO CHECK YOUR SLEEPINESS SCORE, TOTAL THE POINTS
Score

1-6

Congratulations! You are getting enough sleep!

7-8

Your score is average

9+

Seek the Advice of Dr. Victor Zeines without delay

If you do have some form of sleep apnea a complimentary sleep consultation can be set up by call my office for a sleep appointment.

To schedule an appointment that will test using ultrasound how closed your airway actually is call:
NYC office 212-754-2222
Woodstock office 845-657-2322

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