Sleep Evaluation Form

Sleep Evaluation
The Profiler takes about 02 minutes - Please complete all the fields
Full Name *

First Name Last Name
E-mail *
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Birth Date *

Month Day Year
Sex *

Male Female
Insurance Name
Insurance Type
Insurance ID#
Insurance Group
BMI Calculator *
Do you snore *

Yes No Dont know
Your Snoring is: *

Slightly louder than breathing As loud as talking Louder than talking Very loud Does not apply
How often do you Snore? *

Almost every day 3-4 times a week 1-2 times a week Never or almost never
Does your Snoring bother other people? *

Yes No
Has anyone noticed that you quit breathing during your sleep? *
Are you tired after sleeping? *
Are you tired during wake time? *

Almost every day 3-4 times a week 1 time a month Never or almost never
Have you ever nodded off or fallen asleep while driving? *

Yes No
If yes, how often does it occur? *

Almost every day 3-4 times a week 1-2 times a week Never or almost never
Do you have high blood pressure? *

Yes No Dont Know
Would you like a sleep disorder specialist to contact you if your test results are high?

Yes No
How did you hear about this test?
Additional Comments
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