NM800077 (Rev. 09/19/16) Worksheet Only – Not a Medical Record Document
UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
Please answer the following questions below to determine if you might be at risk.
Yes No Snoring?
Ο Ο Do you Snore Loudly (louder than talking or loud enough to be heard through closed doors?
Yes No Tired?
Ο Ο Do you feel Tired, Fatigued, or Sleepy during the daytime?
Yes No Observed?
Ο Ο Has anyone Observed you Stop Breathing during your sleep?
Yes No Pressure?
Ο Ο Do you have or are being treated for High Blood Pressure?
Ο Ο Body Mass Index more than 35?
Ο Ο Age older than 50?
Yes No Neck size large?
Ο Ο Do you have a Neck that Measures more than 16 inches / 40 cm around (measure at Adam’s Apple)?
Ο Ο Gender = Male?
Low risk of OSA: Yes to 0-2 questions
Intermediate risk of OSA: Yes to 3-4 questions
High risk of OSA: Yes to 5-8
Adapted from Chung F et al. Anesthesiology 2008; 812-821, and Chung F et Br J
Anaesth 2012; 108: 768-775.