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Patient History Questionnaire for Possible Need for Oxygen Supplementation

Posted By Frank O. McGehee, Jr, MD, CCN, Sunday, August 9, 2015
Updated: Thursday, May 7, 2015
Circle the best answer below
1. Do you sometimes snore? Yes No
2. Has your snoring ever bothered other people? Yes No
3. Has anybody noticed you sometimes quit breathing during sleep? Yes No
4. Do you sometimes feel tired or fatigued after you sleep? Yes No
5. Do you have shortness of breath when you are awaking? Yes No
6. Do you awake during sleep? Yes No
7. Have you ever been diagnosed with Asthma? Yes No
8. Have you ever been diagnosed with Bronchitis? Yes No
9. Have you ever been told you have Emphysema? Yes No
10. Have you ever been told you have COPD? Yes No
11. Have you ever been told you have any type of lung disease? Yes No
12. Do you sometimes awake feeling like you can’t catch your breath? Yes No
13. Do you sometimes awake from sleep feeling like your heart is racing? Yes No
14. Do you feel short of breath during exercise? Yes No
15. You sleep on how many pillows? ______________
16. Do you have High Blood Pressure? Yes No
17. Have you ever been told you have Heart Disease? Yes No
18. Have you ever been told that you have Congestive Heart Failure? Yes No
19. Have you ever been told you have Sleep Apnea? Yes No
20. Have you ever used a CPAP? Yes No How Long? ____________
21. How would you describe your sleep? ________________________________________
__________________________________________________________________________
__________________________________________________________________________
If you answered “yes” to several of these questions, you may be “hypoxic” or in need of oxygen supplementation. Ask us for details about testing.

Tags:  hypoxia  oxygen supplementation  sleep apnea  snoring 

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