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 number was sent on the paperwork sent to you)
example Reading ID 123456
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
1. Sitting and reading*
Chance of dozing
2. Watching television*
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

AFib is the most common type of irregular heartbeat that often causes the heart to beat too quickly. One of the biggest concerns with AFib is the risk of stroke. In fact, people with AFib have approximately 5 times greater risk of stroke than those who do not have AFib.
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?
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Patient CardioSleep Questionnaire

SLEEP HEALTH

CARDIAC HEALTH