Adult Sleep Questionnaire

Adult Sleep Questionnaire

This form helps to screen for sleep apnea in adults to see if a sleep test is needed. If you suspect you have sleep apnea and you wish to be seen by Dr. Liu at the clinic, please click submit and someone will reach out to you to book an appointment.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date

MonthDayYear
Date
Check all that applies to you. If you answered YES to 3 or more, you may be at risk for sleep apnea.
STOP Bang Questionnaire (Quick risk assessment of Sleep Apnea). Please check all the ones that apply to you that are a YES. If you answered yes to 3-4 questions, you are intermediet risk. If you answered yes to 4-8 questions, you are high risk.
Any other comments or concerns?
Thank you for taking the time to fill ou this form. If you wish to be seen by Dr. Liu at the clinic, please click submit and someone will reach out to you to schedule an appointment.
Should be Empty: