Sleep Apnea Screener
This is a screening form to determine the need for a home sleep test, to see if you have a sleep disorder. How you sleep can affect your quality of life, especially your cardiovascular health. Long term sleep apnea can negatively affect your well-being, can lead to heart arrhythmia, increase your chance for diabetes as well as strokes. Sleep disorders CAN be treated effectively.
Name
*
First Name
Last Name
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Your Weight
Your Height
Please answer the following questions by checking if the answer is yes.
*
Do you snore?
Do you often feel tired, fatigued, or sleepy during the day?
Has anyone observed that you stop breathing or choke or gasp during your sleep?
Do you have or are you being treated for High Blood Pressure?
Is your age over 50 years old?
Is your neck size larger than 15" (Females) or 16.5" (Males)?
Have you ever been given a CPAP machine?
*
Yes
No
If you have been given any form of CPAP, do you use it nightly?
*
Yes
No
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