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Clinical History
Comprehensive Intake & OSA Screening
01
Reason for Evaluation
OSA
STOP-BANG Questionnaire
Obstructive Sleep Apnea Screening
S - Snoring? (Do you snore loudly?)
Yes
No
T - Tired? (Do you often feel tired, fatigued, or sleepy during daytime?)
Yes
No
O - Observed? (Has anyone observed you stop breathing during sleep?)
Yes
No
P - Pressure? (Do you have or are being treated for high blood pressure?)
Yes
No
B - BMI? (BMI more than 35 kg/m2?)
Yes
No
A - Age? (Age over 50 years old?)
Yes
No
N - Neck? (Neck circumference > 16in/40cm?)
Yes
No
G - Gender? (Gender male?)
Yes
No
02
Typical Sleep Patterns
Typical Bedtime
Typical Wake Time
Sleep Latency (mins)
0-15 minutes
15-30 minutes
30-60 minutes
Over 60 minutes
Nightly Awakenings
None
1 time
2 times
3 times
4+ times
Reason for awakenings
Total Sleep Time
Less than 5 hours
5-6 hours
6-7 hours
7-8 hours
8-9 hours
9+ hours
Weekend Schedule
Similar to weekday
Sleep/Wake later
Extended catch-up sleep
Nap Frequency
Never
Occasional (1-2/wk)
Frequent (3-5/wk)
Daily
When you try to relax in the evening or sleep at night, do you ever have unpleasant, restless feelings in your legs that can be relieved by walking or movement?
Yes
No
03
Social History
Nicotine/Tobacco Use
Never used
Former user
Current user
Alcohol Use
None
Occasional
Moderate (1-2/day)
Heavy
Caffeine Intake
None
Low (1-2 cups)
Moderate (3-4 cups)
High (5+ cups)
Exercise Routine
None/Sedentary
Light (1-2 days/wk)
Moderate (3-4 days/wk)
Active (5+ days/wk)
Employment Status
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