VirtuOx CardioSleep Questionnaire

Patient CardioSleep Questionnaire

Please complete this form and click submit
Name

First NameLast Name
Date of Birth

MonthDayYear
Email
example@example.com
VirtuOx Testing Reading ID # (This 7-digit number was sent on the paperwork you received - optional but helps us link to your results)
example Reading ID 1234567
SLEEP HEALTH

How likely are you to doze off or fall asleep in the following situations? You should rate your chances of dozing off, not just feeling tired. Even if you have not done some of these things recently, try to determine how they would have affected you. For each situation, decide whether or not you would have:
- No chance of dozing
- Slight chance of dozing
- Moderate chance of dozing
- High chance of dozing
2. Watching television
Chance of dozing
1. Sitting and reading
Chance of dozing
3. Sitting inactive in a public place (e.g. a theater or meeting)
Chance of dozing
4. As a passenger in a car for an hour without a break
Chance of dozing
5. Lying down to rest in the afternoon when circumstances permit
Chance of dozing
6. Sitting and talking to someone
Chance of dozing
7. Sitting quietly after lunch without alcohol
Chance of dozing
8. In a car, while stopped for a few minutes in traffic
Chance of dozing
CARDIAC HEALTH

People who have trouble breathing during sleep can sometimes have problems with their heart too. This is more common than most people realize. The good news is that when these symptoms are caught early, there are many options available. The questions below help us check for any heart symptoms you may have. Your answers help us make sure you are getting the right care and that nothing important gets missed.
1. Does your heartbeat ever feel odd or irregular?
2. Do you ever feel like your heart is racing?
3. Does your heart ever feel like it is pounding extra hard?
4. Do you sometimes feel dizzy or lightheaded?
5. Have you fainted or almost fainted in the last year?
6. Do you ever feel weak or numb on one side of your body?
7. Do you have periods of darkness or temporary loss of sight?
8. Do you have temporary vison loss?
Do you currently have?
9. Do you have history of heart disease?
Do you currently have?
Signature
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Patient CardioSleep Questionnaire

SLEEP HEALTH

CARDIAC HEALTH