Plagued with snoring problems?

Do you wake up tired? Do you fall asleep in situations where you shouldn't, like meetings, driving or while watching TV?

THERE IS A SOLUTION!

Nationwide Respiratory

What is OSA?

Obstructive Sleep Apnea (OSA) is a serious, potentially life-altering and life-threatening condition that is easily identified and effectively treated.

OSA is when a person stops breathing repeatedly during sleep because the airway collapses and prevents air from getting into the lungs.

During sleep, relaxation of the muscles at the base of the throat causes the airway to close. This condition causes extremely loud snoring, followed by silent periods when breathing has stopped. These episodes where breathing ceases are called apneas. During apnea episodes, blood oxygen levels drop dramatically.

What are the symptoms:

  • Excessively loud snoring
  • Gasping and choking for breath
  • Frequent awakening during the night
  • Abnormal daytime sleepiness or fatigue
  • Headaches
  • Limited attention
  • Memory loss

Berlin Questionnaire - SLEEP QUESTIONNAIRE

*Name:     * = REQUIRED
Please tell us how would you like us to respond to your question and/or comments? Phone    Email
*Email:
*Address:
*City: *State: *Zip:
*Phone:
 
Patient Name:
Date: Height: Weight:
Age: Neck Size: Sex: M     F
 
1. Has your weight changed? Yes     No
2. Do you snore? Yes   No   Not Sure
    If you snore:
3. Your snoring is...

Slightly louder than breathing
Louder than talking
As loud as talking
Very Loud

 
4. How often do you snore?

Almost everyday
3-4 times a week
1-2 times a week
Never or almost never

 
5. Does your snoring bother other people?

Yes
No
6. Has anyone noticed that you quit breathing during your sleep?

Almost everyday
3-4 times a week
1-2 times a week
Never or almost never

 
7. Are you tired after sleeping?

Almost everyday
3-4 times a week
1-2 times a week
Never or almost never

 
8. Are you tired during waketime?

Almost everyday
3-4 times a week
1-2 times a week
Never or almost never

 
9. Have you ever nodded off or fallen asleep while driving?
Yes    
No
If yes, how often does this occur?

Almost everyday
3-4 times a week
1-2 times a week
1-2 times a month
Never or almost never

 
10. Do you have high blood pressure?
Yes     No     Not Sure
 
Final results:
Two or more checked categories indicates high likelihood of sleep apnea.
 
Visit our Web site at www.nationwiderespiratory.com for more information or call 800.969.1213 for a provider in your area.