Sleep Evaluation Form

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 *

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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