SLEEP ASSESSMENT
This form determines the need for a home sleep test. How you breathe can affect your quality of life and especially your cardiovascular health but can easily be treated.
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Email *
How likely are you to doze off while doing the following activities? 0=never, 1=slight, 2= moderate and 3=high *
0
1
2
3
Being a passenger in a motor vehicle for an hour or more
Sitting and talking to someone
Sitting and reading
Watching TV
Sitting inactive in a public place
Lying down to rest in the afternoon
Sitting quietly after lunch without alcohol
In a car, while stopped for a few minutes in traffic
Check yes or no to each question. *
Yes
No
Have you been told that you snore?
Does your family have a history of premature death in sleep?
Do you have Diabetes?
Have you ever been told you Coronary Artery Disease?
Have you been told that you have high blood pressure?
Have you ever experienced an irregular heart beat?
Are you taking opiod pain medications on a regular basis?
Have you ever been diagnosed with sleep apnea?
Do you awaken from sleep with chest pain or shortness of breath?
Has anyone said that you seem to stop breathing while sleeping?
Is your neck size larger than 15" (Female) or 16.5" (Male)?
Have you ever had a stroke?
Have you ever been told you have congestive heart failure?
Do you have or did you ever have atrial fibrillation?
Have you ever been given a CPAP device?
IF yes, do you use a CPAP device nightly?
Are you comfortable with your CPAP and satisfied with the progress?
Patient Name *
Patient DOB *
MM
/
DD
/
YYYY
E-Signature *
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