Easmed - Sleep Health and Apnea Screening Survey

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Your Name* This field is required.

Prefix

First Name

Last Name

2

Department* This field is required.

3

Your Phone Number* This field is required.

4

Your Email* This field is required.

example@example.com

5

Number of years in Service* This field is required.

6

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

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

YESNO

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

YESNO

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

YESNO

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

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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

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

YESNO

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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

18

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

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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!

*In submitting this form I agree to my details being used by Easmed/The Air Station for the purposes of data collection and I consent to receive emails from Easmed & The Air Station. The information will only be accessed by Easmed/The Air Station and their partners. I understand my data will be held securely and will not be distributed to third parties outside of Easmed/The Air Station's partners. I have a right to change or access my information. I understand that I can unsubscribe from the mailing list anytime after submission.