Airway Questionnaire for Obstructive Sleep Apnea (OSA)

Do you breathe through your mouth during the day? No ____ Yes____ 
What is your breathing difficulty?  Mild____ Moderate____ Severe____

Do you breathe through your mouth when you sleep? No____ Yes____ 
Does this occur: Occasionally ____ Moderately ____ Always ____

Do you breathe through your mouth during the day? No____ Yes____ 
Does this occur: Occasionally ____ Moderately ____ Always ____

Do you snore? No ____ Yes ____
Is your snoring: Mild ____ Moderate ____ Severe ____

Are you tired during the day? No ____ Yes ____ 
Is your daytime tiredness: Mild ____ Moderate ____ Severe ____

Do you have Sleep Apnea? No ____ Yes ____ 
When did it start or was diagnosed?______________________________ 
Is your Sleep Apnea: Mild _____ Moderate ____ Severe ____

Do you have difficulties sleeping at night? No ____ Yes ____ 
Are your sleep difficulties: Mild ____ Moderate ___ Severe ____

Do you toss and turn a lot when sleeping? No ____ Yes ____ 
Is the tossing and turning: Mild ____ Moderate ____ Severe ____

Do you wake up at night unable to catch your breath? No ____ Yes ____ 
Does this occur: Occasionally ____ Moderately ____ Frequently ____

Do your legs and/or arms jerk at night? No ____ Yes ____ 
Is the leg and arm jerking: Mild ____ Moderate ____ Severe ____

Do you sleep on your? Back ____ Sides ____ Stomach ____ Other _________ 
Do you have high blood pressure? No ____ Yes ____ 
Is it: Mild____ Moderate ____ Severe ____ 
What is your blood pressure? ____________

Do you smoke? No ____ Yes ____ 
Packs per day ____ Cigarettes per day ____ Other ________ 
Number of Years ____
Any lung (pulmonary) conditions? No ____ Yes ____ 
What are the conditions? ____________________________________________________

Have you had surgery for your breathing or Sleep Apnea conditions? No ____ Yes ____ 
What procedures have been done? ____________________________________________ 
________________________________________________________________________

Have you had a Sleep Study? No ____ Yes ____ (If yes, please send copy of report)

Dr. Larry M. Wolford treats Airway Obstructive Sleep Apnea Syndrome (OSA). Please contact Dr. Larry Wolford’s office using our online contact form or call 214-828-9115 if you would like to schedule an appointment.