AirwayZ Inventory

Adult Screening Questionnaire

AirwayZ Airway Health Inventory — Adult (Ages 18+)
A irway Z
Instrument 4 · Adult · Ages 18+
A irway Z
Airway Health Inventory
Adult
Ages 18+ · Self-Report
TreatOrigin Productions, LLC
Name
Age
Date
Referring provider
Primary physician
Dentist
How to complete
Answer based on your own experience over the past three months unless otherwise noted. There are no right or wrong answers. This form is a starting point for a clinical conversation, not a diagnosis. Complete all sections that apply to you.
Severity scale
0 Not present   1 Mild   2 Mild-moderate   3 Moderate
4 Moderate-pronounced   5 Pronounced

Initial column = today  ·  F/U = after 3 months of care
Section A · Daytime Sleepiness & Dozing Tendency
How likely are you to doze off or fall asleep in the following situations? Rate your tendency honestly, based on your usual life, not how you think you should feel. · 0 = Would never doze · 1 = Slight chance · 2 = Moderate chance · 3 = High chance
Situation 0
Never 		1
Slight 		2
Moderate 		3
High
Reading or working quietly on your own
0
1
2
3
Watching a show or movie in the evening
0
1
2
3
Sitting through a meeting, class, or presentation
0
1
2
3
Riding as a passenger for 30 to 60 minutes
0
1
2
3
Resting quietly in the afternoon when you have the chance
0
1
2
3
Sitting quietly after a meal
0
1
2
3
Waiting in a lobby, waiting room, or airport without a specific task
0
1
2
3
Sitting at a desk or computer when you are trying to focus but not fully engaged
0
1
2
3
Section B · Nighttime & Sleep
Snoring frequency · Mark how often each pattern occurs
Never Rarely Sometimes Most nights Every night
Do you snore at all?
During sleep · Severity: 0 (not present) through 5 (pronounced)
0 1 2 3 4 5 F/U
Snoring loudness: how loud is your snoring when it occurs? Loud snoring is a Berlin Category 1 item and a primary STOP-Bang criterion.
0
1
2
3
4
5
Waking with gasping, choking, or a sudden sensation of not being able to breathe?
0
1
2
3
4
5
Sleeping with mouth open?
0
1
2
3
4
5
Excessive sweating during sleep, beyond what room temperature would explain?
0
1
2
3
4
5
Restless legs, leg kicking, or excessive movement during sleep?
0
1
2
3
4
5
Night terrors, sleepwalking, or episodes of apparent wakefulness with no memory afterward?
0
1
2
3
4
5
Teeth grinding or clenching during sleep (bruxism)? Bruxism is significantly more common in individuals with OSA and may reflect a compensatory arousal mechanism.
0
1
2
3
4
5
Talking during sleep?
0
1
2
3
4
5
Waking unrefreshed despite adequate hours of sleep?
0
1
2
3
4
5
Difficulty waking in the morning, despite sleeping a full night?
0
1
2
3
4
5
Dry mouth upon waking?
0
1
2
3
4
5
Morning headaches before getting out of bed?
0
1
2
3
4
5
Waking with a sour taste, burning sensation in the throat, or chronic nighttime cough? Nocturnal acid reflux and GERD are both consequences and triggers of airway events during sleep.
0
1
2
3
4
5
Nighttime patterns · Frequency-based
0 times 1 time 2 times 3 or more
How many times do you typically wake to use the bathroom at night? Nocturia is a recognized consequence of negative intrathoracic pressure changes during apneic events, signaling increased atrial natriuretic peptide release.
Often Sometimes Never Unsure
Do your symptoms seem worse when sleeping on your back? Positional OSA, significantly worse in the supine position, is present in approximately 50% of OSA patients and influences treatment options.
Do you sleep in unusual positions, or reposition your head, neck, or jaw to breathe or sleep more comfortably?
Observed or reported by yourself or a bed partner Yes No Not sure
Has anyone told you that you snore loudly? Partner-reported loud snoring is a Berlin Category 1 and STOP-Bang criterion.
Has anyone observed you stop breathing, pause your breathing, or appear to struggle to breathe during sleep?
Have you or a bed partner noticed choking or gasping sounds during your sleep?
Have you noticed your snoring cuts off abruptly before resuming (interrupted snoring)?
If yes to any witnessed breathing event above, please describe:
Section C · Daytime Symptoms
During waking hours · Severity: 0–5
0 1 2 3 4 5 F/U
Feel fatigued during the day despite sleeping? Tiredness is a Berlin Category 2 item and a STOP-Bang criterion.
0
1
2
3
4
5
Have brain fog, memory lapses, word-finding difficulty, or trouble staying mentally sharp or focused? OSA is independently associated with an increased risk of Alzheimer's disease, with evidence that treatment reduces this risk.
0
1
2
3
4
5
Have chronic nasal congestion or consistent difficulty breathing through the nose?
0
1
2
3
4
5
Have recurring headaches at least once a month, apart from morning waking headaches?
0
1
2
3
4
5
Have mood changes, irritability, low motivation, or emotional flatness not fully explained by circumstances?
0
1
2
3
4
5
Have symptoms of depression: persistent low mood, loss of interest, or a significant shift in your baseline?
0
1
2
3
4
5
Have anxiety, excessive worry, or persistent tension that seems disproportionate to your circumstances?
0
1
2
3
4
5
Experience reduced libido or sexual dysfunction that seems related to fatigue or low energy? Sexual dysfunction is a recognized comorbidity of OSA through hormonal disruption and vascular effects of intermittent hypoxia.
0
1
2
3
4
5
For men: experience erectile dysfunction? Erectile dysfunction prevalence increases with OSA severity and is driven by endothelial dysfunction and sleep fragmentation.
0
1
2
3
4
5
Have difficulty swallowing, a chronic need to clear your throat, or hoarseness?
0
1
2
3
4
5
Have daytime acid reflux or heartburn?
0
1
2
3
4
5
Yes No Not sure
Do you feel sleepy or fatigued at least three times per week regardless of how much you slept? Berlin Category 2 criterion.
Have you ever fallen asleep while driving, or has drowsiness ever been a concern while driving? Drowsy driving is a Berlin Category 2 criterion and a serious safety risk.
Do you rely on caffeine, stimulants, or energy drinks to get through the day?
Section D · Oral, Jaw & Airway: The AirwayZ Clinical Fingerprint
These domains are not captured by standard OSA screening tools · Severity: 0–5
0 1 2 3 4 5 F/U
Rest with mouth open at baseline: lips apart, tongue low, jaw dropped when relaxed and not speaking or eating? Resting oral posture reflects the default position of the orofacial structures at rest.
0
1
2
3
4
5
Breathe through the mouth as a habitual daytime pattern?
0
1
2
3
4
5
Have difficulty chewing comfortably with lips fully closed?
0
1
2
3
4
5
Have jaw pain, clicking, popping, or locking?
0
1
2
3
4
5
Clench or grind your teeth during the day?
0
1
2
3
4
5
Have jaw stiffness or discomfort upon waking in the morning?
0
1
2
3
4
5
Have chronic neck pain or tension headaches?
0
1
2
3
4
5
Have poor posture or a forward head position, or has anyone commented on this? Forward head posture is biomechanically linked to reduced pharyngeal airway tone through displacement of the hyoid and suprahyoid musculature.
0
1
2
3
4
5
Oral posture and structure · Yes / No / Not sure
Roof Bottom Unsure
Where does your tongue rest when your mouth is relaxed and closed? Correct resting posture: tongue flat against the palate, lips together, teeth lightly touching. Low tongue posture is an orofacial myofunctional disorder associated with OSA.
Yes No Not sure
Can you keep your lips together comfortably at rest, without effort or strain? Lip incompetence is associated with habitual mouth breathing and altered orofacial function.
Do you notice scalloping or indentations along the edges of your tongue? Tongue scalloping indicates macroglossia relative to the dental arch and is a recognized OSA risk factor observed during orofacial examination.
Do you breathe primarily through your nose or mouth during the day at rest?
Nose
Mouth
Mixed
Have you been told you have a small jaw, recessed chin, narrow palate, or crowded teeth? These craniofacial features are associated with reduced pharyngeal airway dimensions.
Has anyone ever told you that your face developed in a longer or narrower pattern, or that you have a more vertical facial growth pattern? A long, narrow face with increased vertical growth is associated with reduced upper airway dimensions, narrowed palate, and higher OSA risk. This structural pattern is often visible from the facial profile alone.
Do you have a history of orthodontic treatment, or were teeth extracted for crowding?
Has a dentist or doctor ever noted a thick or short neck, or commented on your neck size? Neck circumference is a STOP-Bang criterion. A provider-noted short or thick neck is the patient-reportable equivalent.
Have you been evaluated for or diagnosed with tongue tie (ankyloglossia)?
Section E · STOP-Bang and Berlin Risk Flags
These items correspond directly to the validated STOP-Bang and Berlin questionnaire criteria · Yes / No / Not sure
Yes No Not sure
Snoring: do you snore loudly? [STOP-Bang · Berlin C1]
Tiredness: do you often feel tired, fatigued, or sleepy during the daytime? [STOP-Bang · Berlin C2]
Observed apnea: has anyone observed you stop breathing during your sleep? [STOP-Bang · Berlin C1]
Blood Pressure: do you have, or are you being treated for, high blood pressure? [STOP-Bang · Berlin C3] 80% of patients with resistant hypertension have comorbid OSA.
BMI: is your BMI above 35, or has a physician described you as significantly overweight? [STOP-Bang · Berlin C3]
Age: are you 50 years of age or older? [STOP-Bang]
Neck: has a provider noted a large or thick neck, or do you wear a collar larger than 17 inches (men) or 16 inches (women)? [STOP-Bang]
Gender: are you male, or were you assigned male at birth? [STOP-Bang]
Section F · Medical History & Systemic Flags
Please check all diagnoses you have received or are currently being treated for
Check all that apply:
✓
Sleep apnea (diagnosed)
✓
UARS (upper airway resistance)
✓
Insomnia
✓
TMJ disorder
✓
ADHD
✓
Anxiety disorder
✓
Depression
✓
Acid reflux / GERD
✓
Atrial fibrillation
✓
Hypothyroidism
✓
Type 1 diabetes
✓
Type 2 diabetes
✓
Prediabetes
✓
High cholesterol / triglycerides
✓
Chronic kidney disease
✓
Heart attack / coronary artery disease
✓
Heart failure
✓
Stroke or TIA
✓
Alzheimer's / dementia (self or family)
✓
Ehlers-Danlos / joint hypermobility / Marfan
✓
Autism spectrum disorder
✓
Asthma
✓
COPD
✓
Pulmonary hypertension
✓
PCOS
✓
Gout
Treatment and history
Are you currently using CPAP or an oral appliance?
Yes No Not sure
Have your tonsils or adenoids been removed?
Have you had a formal sleep study (polysomnography or home sleep test)?
Have you been evaluated by an ENT, sleep specialist, or oral medicine provider?
Do you smoke, or have you smoked regularly in the past? Smoking is an independent OSA risk factor through upper airway inflammation and reduced mucociliary clearance.
Do you drink alcohol regularly, or use sleep medications, sedatives, or muscle relaxants? Alcohol and sedatives reduce upper airway muscle tone, increasing airway collapsibility during sleep.
Do you have unusually flexible or "double-jointed" joints, or have been told you are hypermobile?
Is there a family history of snoring, sleep apnea, recessed jaw, crowded teeth, or tonsil and adenoid problems?
Section G · Women's Health
Complete if applicable · Hormonal changes throughout a woman's lifespan are independently associated with OSA risk
Yes No N/A
Are you currently perimenopausal or postmenopausal? Postmenopausal women have a substantially higher risk of OSA. The risk is further elevated after surgical menopause.
If postmenopausal, was your menopause:
Yes No N/A
Are you currently pregnant or were you pregnant in the past two years? OSA prevalence increases as pregnancy progresses and is associated with preeclampsia, gestational diabetes, and preterm delivery.
Did you experience preeclampsia, gestational hypertension, or gestational diabetes during any pregnancy? All three are strongly and independently associated with untreated OSA during pregnancy.
Have you been diagnosed with PCOS?
Are your menstrual cycles irregular, absent, or accompanied by unusual fatigue or mood changes?
Are you currently on hormone replacement therapy? HRT is associated with a 40–50% reduction in OSA prevalence in postmenopausal women in large cohort studies.
Section H · Self-Concern & Quality of Life
Based on the OSA-18 quality-of-life framework · 0 = No concern or impact · 10 = Severe concern or impact
0 1 2 3 4 5 6 7 8 9 10
How concerned are you that your breathing or sleep is affecting your health, cognitive function, or long-term health?
0
1
2
3
4
5
6
7
8
9
10
How much is your sleep or breathing affecting your daily functioning, relationships, or work?
0
1
2
3
4
5
6
7
8
9
10
How would you rate your overall quality of life right now, with sleep and breathing factored in? 0 = Very poor  ·  5 = Moderate  ·  10 = Excellent
0
1
2
3
4
5
6
7
8
9
10
For the Clinician
This instrument is part of the AirwayZ Airway Health Inventory , a five-instrument comprehensive screening tool spanning birth through adulthood, developed by Elizabeth Walker, DMD, MSD. The adult instrument incorporates an original AirwayZ daytime sleepiness and dozing profile, along with validated risk domains derived from the STOP-Bang Questionnaire (Chung et al., 2008) and the Berlin Questionnaire (Netzer et al., 1999), with those validated items explicitly labeled for clinical reference. Section D contains the AirwayZ-original orofacial, myofunctional, and craniofacial domain not captured in any standard OSA screener, incorporating orofacial myofunctional disorder criteria (ASHA, 2023), dental sleep medicine examination standards (AADSM, 2025), and postural-airway literature. Section F includes the full comorbidity landscape established across the AirwayZ evidence architecture, including the Alzheimer's disease association (adjusted HR 2.12, Tsai et al., 2020), EDS/OSA co-prevalence (Sedky et al., 2019), and OSA-cardiovascular associations (AHA Scientific Statement, 2021). Section G incorporates postmenopausal OSA risk (Wisconsin Sleep Cohort; American Journal of Epidemiology, 2018) and obstetric associations. Composite scoring is intentionally absent. STOP-Bang items are labeled for direct clinical extraction if a scored result is needed. Individual item patterns and clinical judgment should guide next steps.
A Note for Patients
What this inventory is
A starting point for a clinical conversation, not a diagnosis. Many of the patterns this form captures are well understood, highly prevalent, and when identified, often addressable in ways that make a real and lasting difference to sleep, cognition, mood, and overall health.
What to do next
Share this completed form with your physician, dentist, sleep specialist, or any provider who treats the conditions mentioned here. If your provider is not familiar with airway-focused care, visit airwayz.com to find an affiliated clinician near you.
About Section D
The oral, jaw, and airway section captures patterns that standard medical screening tools do not ask about. These findings are recognized in dental sleep medicine, myofunctional therapy, and craniofacial research as independent contributors to airway dysfunction. A dentist or orthodontist with airway training is often the right starting point.
About mood and cognitive findings
Depression, anxiety, brain fog, and memory concerns appear in this form because they are documented consequences of disrupted sleep physiology, not character assessments. When airway contributors are identified and addressed, these patterns frequently improve alongside sleep quality.
A irway Z
Elizabeth Walker, DMD, MSD  ·  TreatOrigin Productions, LLC
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