Sleep Disorder Assessment

This form determines the need for you to have a sleep test, which will evaluate if you have a Sleep Disorder. Sleep Disorders negatively affect your cardiovascular health and well being, but can be effectively treated.

Please note that this form will be emailed to the email you input below as well as to our office for review.

Part 1

Part 2

Epworth Sleepiness Scale

How likely are you to doze off while doing the following activities? Please use the following scale: 0 = never, 1 = slight, 2 = moderate, 3 = high. Check one of the following numbers.