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.

Date (Format: YYYY-MM-DD)(required)

Would You like to be contacted by our office about the results of this survey? (required)

Part 1

1. Have you ever been told you have Congestive Heart Failure?

2. Have you ever been told you have Coronary Artery Disease?

3. Have you ever had a stroke?

4. Do you take medications for high blood pressure?

5. Have you ever experienced irregular heart rhythms? (A-Fib)

6. Have you ever been told that you stop breathing at night?

7. Do you have Diabetes?

Part 2

1. Have you been told that you snore loudly?

2. Do you clench or grind your teeth at night?

3. Do you awaken with chest pain or shortness of breath?

4. Has anyone in your family ever died in their sleep?

5. Is your neck size larger than 15.5 (female) or 17.0 (male)?

6. Have you ever been diagnosed with Obstructive Sleep Apnea?

--If yes, are you using your apparatus every night?

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.

1. Being a passenger in a motor vehicle for an hour or more

2. Sitting and talking to someone

3. Sitting and reading

4. Watching TV

5. Sitting inactive in a public place

6. Lying down to rest in the afternoon

7. Sitting quietly after lunch without alcohol

8. In a car, while stopped for a few minutes in traffic.