MEDICAL A.R.E.S. QUESTIONNAIRE
Name
First Name
Middle Initial
Last Name
Weight (lbs)
Age
Height: Feet
Inches
DOB: Month
DOB: Day
DOB: Year
Gender
Female
Male
Neck size (inches)
Have you been diagnosed or treated for any of the following conditions?
Rows
YES
NO
High blood pressure
Heart disease
Diabetes
Lung disease
Insomnia
Narcolepsy
Sleeping medication
Stroke
Depression
Sleep apnea
Nasal oxygen use
Restless leg syndrome
Morning headache
Pain medication
STOP B.A.N.G. QUESTIONNAIRE
Do you snore loudly (loud enough to be heard through a closed door)?
YES
NO
Has anyone observed you stop breathing or choking/gasping during your sleep?
YES
NO
Do you often feel tired, fatigued, or sleepy during the daytime?
YES
NO
Do you have or are you being treated for high blood pressure?
YES
NO
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