SSS Sleep Apnea Evaluation Submission Form

Sleep Apnea Evaluation: Submission Form
Name*
Date Of Birth*

MonthDayYear
Date
Email*
example@example.com
Preferred Contact Method
What caused you to seek evaluation for Sleep Apnea?*
Epworth Sleepiness Scale:

How likely are you to doze off or fall asleep during the following Situations. Even if you have not been in the situations recently, try to imagine how you would behave.

0 = No chance of dozing

1 = Slight chance of dozing

2 = Moderate chance of dozing

3 = High chance of dozing
Sitting and reading:*

0

1

2

3

0 is No chance, 3 is High Chance
Watching TV:*

0

1

2

3

0 is No Chance, 3 is High Chance
Sitting, inactive in a public place:*

0

1

2

3

0 is No Chance, 3 is High Chance
As a passenger in a car for an hour without a break:*

0

1

2

3

0 is No Chance, 3 is High Chance
Lying down to rest in the afternoon when circumstances permit:*

0

1

2

3

0 is No Chance, 3 is High Chance
Sitting and talking to someone:*

0

1

2

3

0 is No Chance, 3 is High Chance
Sitting quietly after lunch (without alcohol):*

0

1

2

3

0 is No Chance, 3 is High Chance
In a car, while stopped for a few minutes in traffic:*

0

1

2

3

0 is No Chance, 3 is High Chance
General Sleep Apnea Questions

Select the answer that best applies.
Do you snore?*

YesNo
How often do you snore?*

Every DayNearly Every DaySometimesNever
Has your snoring ever bothered other people?*

YesNo
Have you ever been told that you stop breathing for periods of time while sleeping?*

YesNo
Do you experience daytime sleepiness?*

YesNo
How often do you feel fatigued after you sleep?*

Every DayNearly Every DaySometimesNever
Have you been treated for Sleep Apnea in the past?*

YesNo
Have you had surgical intervention for Sleep Apnea in the past?*

YesNo
Have you been to a sleep Lab or Sleep Disorder Center for an Evaluation?*

YesNo
If yes, where?
Have you tried using CPAP?*

YesNo
If yes, for how long?
Height*
Weight*
Any Questions, Comments or Concerns?
Phone Number
Please enter a valid phone number.
Should be Empty: