Sleep Apnea Screening
Does your snoring keep your partner up at night? Do you wake up feeling tired or stressed? Fill out our Sleep Apnea Screening Form to see if you may be at risk for sleep apnea.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Do you snore loudly, loud enough to be heard through closed doors?
*
Yes
No
Do you often feel tired, fatigued or sleepy during the day?
*
Yes
No
Has anyone observed you stop breathing during you sleep?
*
Yes
No
Do you have or are you being treated for high blood pressure?
*
Yes
No
Height (in inches)
*
Weight
*
Are you over the age of 50?
*
Yes
No
Is your neck circumference >17 inches for men or >16 inches for women?
*
Yes
No
Gender assigned at birth*
*
Male
Female
Do you have or are you being treated for any of the following? Please check any that apply:
*
COPD
Neuromuscular Disease
Heart Failure
Trouble handling small objects
Currently on Oxygen
Have a pacemaker device
None
I acknowledge that I am submitting my personal information to NGHS, which will be used in accordance to the NGHS Online Privacy Statement.
*
I agree
View the NGHS Online Patient Privacy Statement
Submit
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