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SLEEP APNEA RISK ANALYSIS
First Name
Middle Initial
Last Name
Weight
Pounds
Age
Years
Gender
Male
Female
Height
Feet
Inches
Neck Size
Inches
Date of Birth
Month
Day
Year
ID Number
Optional
Tally ARES
Risk Points
Neck Size
+2 Male ≥ 16.5
+2 Female ≥ 15.0
Score
COMPLETELY FILL IN ONE CIRCLE FOR EACH QUESTION - ANSWER ALL QUESTIONS
Have you been diagnosed or treated for any of the following conditions?
High blood pressure
Yes
No
Stroke
Yes
No
Heart disease
Yes
No
Depression
Yes
No
Diabetes
Yes
No
Sleep apnea
Yes
No
Lung disease
Yes
No
Nasal oxygen use
Yes
No
Insomnia
Yes
No
Restless leg syndrome
Yes
No
Narcolepsy
Yes
No
Morning headaches
Yes
No
Sleeping medication
Yes
No
Pain medication
e.g., vicodin, oxycontin
Yes
No
Co-morbidities
+1 for each Yes response
Score
Do not assign
any points for
these eight
responses
Epworth Sleepiness Scale:
How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling 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 mark the most appropriate box for each situation. (M.W. Johns, Sleep 1991)
0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
0
1
2
3
Sitting and reading
Watching TV
Sitting, inactive, in a public place (theater, meeting, etc)
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 lunch without alcohol
In a car, while stopped for a few minutes in traffic
Epworth Score
TOTAL
the
values from all
8 questions,
If 11 or less
Score = 0
If 12 or more
Score = 2
Score
Frequency
0 - 1 times/week
1 - 2 times/week
3 - 4 times/week
5 - 7 times/week
On average in the past month, how often have you snored or been told that you snored?
Never
Rarely
+1
Sometimes
+2
Frequently
+3
Almost Always
+4
Do you wake up choking or gasping?
Never
Rarely
+1
Sometimes
+2
Frequently
+3
Almost Always
+4
Have you been told that you stop breathing in your sleep or wake up choking or gasping?
Never
Rarely
+1
Sometimes
+2
Frequently
+3
Almost Always
+4
Do you have problems keeping your legs still at night or need to move them to feel comfortable?
Never
Rarely
Sometimes
Frequently
Almost Always
Assign points for
each of the first
three responses
Score
Score
Score
Signature
Area Code
Phone Number
Total all 6 boxes from above
If point total = 4 or 5 (low risk), 6 to 10
(high), and 11 or more (very high risk)
Point Total
Patient Validation:
Submit Form
