OSA 50 Questionnaire

Please either:

1. Download and print the PDF below then fill in and bring in to our staff

OR 2. Fill in and submit the form on the below.

Full Name

Date of Birth

(DD/MM/YYYY)

1. Waist circumference* - Males >102cm or Females >88cm*
*Waist measurement to be measured at the level of the umbilicus.

If yes, Add 3.

2. Has your snoring ever bothered other people?.

If yes, Add 3.

3. Has anyone ever notices that you stop breathing during your sleep?

If yes, Add 2.

4. Are you aged 50 years or over?

If yes, Add 2.

Total Score out of 10

Date Completed

(DD/MM/YYYY)

Have you filled out the Epworth Sleepiness Scale form yet? If not, click here

HAVE ANY QUESTIONS, GET IN TOUCH TODAY