SLEEP APNEA QUESTIONNAIRE
Western Carolina Ear, Nose, and Throat Specialists
MEDICAL HISTORY
Reason for visit: (CIRCLE): snoring, stop breathing in sleep, daytime drowsiness
Other reason: ________________________________
SLEEP HISTORY
Please check all that apply to you:
SNORING:  soft, occasional  heard in adjacent room  heard throughout house  heard
outside house  sleep in separate room from spouse  spouse/family wear earplugs  tried
breathright strips or other device
APNEA (STOPS BREATHING):  more than 5 seconds at a time,  more than 10 seconds at a
time,  awakes gasping for air
PERFORMANCE:  daytime sleepiness,  automobile accidents (how many? ),
 work-related accidents.  performance at school or work affected,  memory or mood
changes,  depression,  morning headaches
USE OF MEDICINES/DEVICES:  tried breathright strips,  tried other device/appliance, 
use alcohol more than 2 times per week,  use sedative or other drugs/herbs
OTHER SLEEP PROBLEMS:  sleep attacks during the day,  sleep paralysis, 
hallucinations,  seizures
ASSOCIATED MEDICAL PROBLEMS:  heart problems,  high blood pressure,
 headaches, reflux, ulcers,  frequent caffeine use,  CPAP use
OTHER MEDICAL COMPLAINTS OR PROBLEMS?
_____________________________________________________________________________
FAMILY HISTORY:  Sleep or neurologic disorders,  thyroid disorders,  heart problems,
other (please describe) ______________________________________________________
THE EPWORTH SLEEPINESS SCALE
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just
tired? This refers to your usual way of life in recent times.
0 = would NEVER dose
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Situation
Sitting and reading
0
1
2
3
Watching TV
Sitting, inactive in a public place (e.g. theater or meeting)
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 a lunch without alcohol
In a car, while stopped for a few minutes in traffic
I hereby certify that the information given above and on the preceding pages is true and accurate to the best
of my knowledge.
Patient's signature: __________________________________
Date: __________________________
I have reviewed the above information with the patient: _______________________________________
INSURANCE AUTHORIZATION FORM
PLEASE SIGN AUTHORIZATION ON THE BOTTOM OF THIS SHEET.
THANK YOU!
INSURANCE INFORMATION
1. NAME OF COMPANY ________________________________________
ADDRESS: __________________________________________________
SUBSCRIBER NAME: ________________________________________
ID #: _______________________ GROUP#: _______________________
2. NAME OF COMPANY ________________________________________
ADDRESS: __________________________________________________
SUBSCRIBER NAME: ________________________________________
ID #: _______________________ GROUP#: _______________________
ASSIGNMENT OF INSURANCE BENEFITS
I hereby authorize direct payment of surgical/medical benefits to Dr. Christopher T.
Wenzel MD, for services rendered by him in person or under his supervision. I
understand that I am financial responsible for any balance not covered by my insurance.
AUTHORIZATION TO RELEASE INFORMATION
I hereby authorize Dr. Wenzel, to release any medical or incidental information that may
be necessary either medical care or in processing applications for financial benefit.
MEDICARE * MEDICAID
I certify that the information given by me in applying for payment is correct. I authorize
release of all records on request. I request that payment of authorized benefits be made on
my behalf.
A photocopy of these assignments shall be valid as the original.
PATIENT (please print) ___________________________ DATE: ______________
SIGNATURE: _____________________________________________
PARENT/GUARDIAN (please print) __________________ DATE: ______________
SIGNATURE: _____________________________________________
OBSTRUCTIVE SLEEP APNEA EXAMINATION
Patient Name: _______________ Date: ___/___/_____
NECK GIRTH _______________ (>17 in, > 16 in)
WEIGHT _________ (>120% ideal BW)
BODY MASS INDEX (>30) ______________
METHODS OF EXAM:  Headlight & Mirror
NOSE
Septal deviation
Right anterior
Left anterior
Right posterior
Left posterior
Anterior nasal valve obstruction
Right
Left
Polyps or lesions _______________
Inferior turbinate enlargement
NASOPHARYNX
Adenoid obstruction
Posterior pillar/palatopharyngeus
UVULA
Elongated
Edema
SOFT PALATE
Position
TONSILS
Size
BASE OF TONGUE
Vallecula
Epiglottic shape
 Fiberoptic Laryngoscopy
NR




mild
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mod
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severe
___
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

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
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

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

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 normal
 retrodisplaced
 absent
1+ 2+ 3+ 4+
open
obstructed
normal abnormal
epiglottis retrodisplaced
omega-shaped
LARYNX
normal abnormal (see FOL exam form)
MANDIBLE
ANGLE'S CLASS
1
2
3
THYROMENTAL DISTANCE ____________ (< 40 mm)
MALLAMPATI SCORE
1
MUELLER'S MANEUVER: obstruction (1-3)
soft palate ___
Examiner's signature: ______________________________
Christopher T. Wenzel, MD
NR: non-remarkable
S: superior
I: inferior
2
3
BOT ___
4