[TAS Malaysia] - Sleep Health and Apnea Screening Survey

1

Kindly key in the name of the person who referred youSkip this question if you’re not referred by anyone to take this assessment

2

Your Name* This field is required.

Prefix

First Name

Last Name

3

Your Phone Number* This field is required.

4

Your Email* This field is required.

example@example.com

5

1. Do you snore loudly?* This field is required.Loud enough to be heard through closed door, or your bed partner elbows you for snoring!

YESNO

6

2. Do you often feel tired, fatigue, or sleepy during the day?* This field is required.

YESNO

7

3. Has anyone observed you stop breathing or choking/gasping during your sleep?* This field is required.

YESNO

8

4. Do you have or are you being treated for High Blood Pressure?* This field is required.

YESNO

9

Enter Height in Meters - For calculation of your Body Mass Index* This field is required.Eg. Height is 1.7m, Enter 1.7

10

Enter Weight in KG - For calculation of your Body Mass Index* This field is required.Eg. Weight is 54kg, Enter 54

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Your Body Mass Index is......* This field is required.

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5. Is your Body Mass Index (BMI) more than 35?* This field is required.BMI = Weight in KG / (Height in Meters x Height in Meters) eg. Wt (100kg) / (Ht 1.5m x 1.5m) = BMI 44

YESNO

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6. Are you above 50 years old?* This field is required.

YESNO

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7. Is your neck size larger than 17 inches/43cm (male) or 16 inches/ 41cm (female)* This field is required.Measured around the adam's apple level

YESNO

15

8. If you are male, please mark YES. If you are female, please mark NO.* This field is required.

YESNO

16

Past & Present Medical Conditions (Tick where applicable)* This field is required.Do you suffer from...

Heart Attack

Diabetes

Atrial Fibrillation/ Arrythmia

Stroke

High Cholesterol

Kidney Disease

NIL

17

Do you drink alcohol?* This field is required.

More than 4 times a week

Less than 4 times a week

I don't drink at all

Used to drink but have stopped now

18

Do you smoke?* This field is required.

More than 4 times a week

Less than 4 times a week

I don't smoke at all

Used to smoke but have stopped now

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Calculation

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Hit "Submit" to see your results in your email inbox!

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