National Sleep Survey

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• Do you have a Commercial Drivers License (CDL)?

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• Date physical is scheduled

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• Physician Details

  In order to facilitate your sleep apnea screening, we need to know your primary care physician. Search our database to locate and select your primary care physician. If you do not find your physician in our database, please use the Add New button to supply his or her details.

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• Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?

  Yes No

• Do you often feel tired, fatigued, or sleepy during the daytime?

  Yes No

• Have you experienced episodes of falling asleep when you should be alert or sleepiness while driving?

  Yes No

• Have you ever had a motor vehicle crash associated with falling asleep while driving?

  Yes No

• Has anyone observed you stop breathing during your sleep?

  Yes No

• Have you ever been told or noticed that you wake from sleep choking or gasping for air?

  Yes No

• Do you wake frequently from sleep or wake up not feeling rested?

  Yes No

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation.*

•  
• Would never dose
• Slight chance of dozing
• Moderate chance of dozing
• High chance of dozing

1. a) Sitting and reading

   • a) Sitting and reading
   • Never
   • Slight
   • Moderate
   • High
2. b) Watching TV

   • b) Watching TV
   • Never
   • Slight
   • Moderate
   • High
3. c) Sitting inactive in a public place (e.g., a theater or a meeting)

   • c) Sitting inactive in a public place (e.g., a theater or a meeting)
   • Never
   • Slight
   • Moderate
   • High
4. d) As a passenger in a car for an hour without a break

   • d) As a passenger in a car for an hour without a break
   • Never
   • Slight
   • Moderate
   • High
5. e) Lying down to rest in the afternoon when circumstances permit

   • e) Lying down to rest in the afternoon when circumstances permit
   • Never
   • Slight
   • Moderate
   • High
6. f) Sitting and talking to someone

   • f) Sitting and talking to someone
   • Never
   • Slight
   • Moderate
   • High
7. g) Sitting quietly after lunch without alcohol

   • g) Sitting quietly after lunch without alcohol
   • Never
   • Slight
   • Moderate
   • High
8. h) In a car while stopped for a few minutes in traffic

   • h) In a car while stopped for a few minutes in traffic
   • Never
   • Slight
   • Moderate
   • High

• Do you have a family history of sleep apnea?

  Yes No
• Do you have any lung or breathing problems?

  Yes No
• Do you have a Pacemaker?

  Yes No
• Nasal oxygen use?

  Yes No
• Do you experience awakenings at night?

  Yes No
• How many times on average do you wake up at night?
• Have you ever had oral or nasal surgery?

  Yes No

• If yes, please describe:

• Do you drink alcohol?

  Yes No

• How often?

  Daily 3-5 times a week Once a week Only on weekends On special occasions

• Any recent change in your intake of alcohol?

  Yes No

• If yes, please describe:

• Please list all of your medications, including over the counter: