SLEEP HISTORY Mark all that apply to you:
Note: If you have been diagnosed with a sleep disorder, please skip the sections below
PATIENT SLEEPINESS SCALE
Step 1: Answer "Yes" or "No" for the following questions (Y or N). If you answer "Yes", also circle the corresponding points in the column to the right.
Step 2: Total the points you circled in the right column and record the score in the space below.
The more criteria you mark on the BANG portion, the greater your risk of having moderate to severe Obstructive Sleep Apnea.
DROWSINESS How likely are you to doze off or fall asleep in the following situations?
The information indicated above is truthful and accurate to the best of my knowledge.
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