Airway Questionnaire for Obstructive Sleep Apnea (OSA)

Airway Questionnaire

Dr. Larry Wolford’s Airway Questionnaire for Obstructive Sleep Apnea (OSA) will assist in diagnosing your sleep-disordered breathing – 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)