Sleep Health and Apnea Screening Survey

1

How did you learn about us?* This field is required.

Doctor's recommendation

Online/ Google Search

Facebook/Instagram

Other Events/ Advertisements

Friends & Family

2

Are you referred by any doctor to take this assessment?* This field is required.

YESNO

3

Kindly key in your doctor's name here.

4

Name* This field is required.

Prefix

First Name

Last Name

5

Email* This field is required.A copy of your responses will be sent.

example@example.com

6

1. Do you snore loudly?* This field is required.Loud enough to be heard through closed door, or your bed partner elbows you for snoring!

YESNO

7

2. Do you often feel tired, fatigue, or sleepy during the day?* This field is required.

YESNO

8

3. Has anyone observed you stop breathing or choking/gasping during your sleep?* This field is required.

YESNO

9

4. Do you have or are you being treated for High Blood Pressure?* This field is required.

YESNO

10

Enter Height in Meters - For calculation of your Body Mass Index* This field is required.Eg. Height is 1.7m, Enter 1.7

11

Enter Weight in KG - For calculation of your Body Mass Index* This field is required.Eg. Weight is 54kg, Enter 54

12

Your Body Mass Index is......* This field is required.

13

5. Is your Body Mass Index (BMI) more than 35?* This field is required.BMI = Weight in KG / (Height in Meters x Height in Meters) eg. Wt (100kg) / (Ht 1.5m x 1.5m) = BMI 44

YESNO

14

6. Are you above 50 years old?* This field is required.

YESNO

15

7. Is your neck size larger than 17 inches/43cm (male) or 16 inches/ 41cm (female)* This field is required.Measured around the adam's apple level

YESNO

16

8. If you are male, please mark YES. If you are female, please mark NO.* This field is required.

YESNO

17

Past & Present Medical Conditions (Tick where applicable)* This field is required.Do you suffer from...

Heart Attack

Diabetes

Atrial Fibrillation/ Arrythmia

Stroke

High Cholesterol

Kidney Disease

Not Applicable

18

Calculation

19

YOU ARE AT LOW RISK OF SLEEP APNEA! Would you like to receive Sleep Health related Articles, Talk Invitations and Promotions from The Air Station?By submitting YES, you will consent to The Air Station sending you information on sleep health via your email.

YESNO

20

YOU ARE AT MODERATE TO HIGH RISK OF SLEEP APNEA. A Home Sleep Study might be able to diagnose your sleep condition further. Would you like more information on Home Sleep Study?* This field is required.By submitting YES, you will consent to The Air Station sending you emails on sleep health information.

YESNO