Welcome!

Please enter the patient's name below:

First Name

Last Name

Sleep Assessment Form

Your doctor is requesting that you complete this Sleep Assessment Form. This form determines the need for you to have a user friendly home sleep test, which will test to see if you have a challenge breathing when you are sleeping. How you breathe can affect your quality of life and especially your cardiovascular health; and can be easily treated.

Date of birth

OK to leave Message?

Yes

No

Regular Dr’s Name

Regular Dr’s Phone

Sleep Questionnaire

Have you ever been given a CPAP device?

Yes

No

If you have been given any form of CPAP, do you use it nightly?

Yes

No

Are you comfortable with your CPAP and satisfied with its use?

Yes

No

If the answer is YES to the all of the above questions, PLEASE STOP and submit the form.

If your answer is NO to any of the above questions, please continue to the following questions:

Sleepiness Scale

How likely are you to doze off while doing the following activities? Please use the following scale:

0 = never

1 = slight

2 = moderate

3 = high

Being a passenger in a motor vehicle for an hour or more

Sitting and talking to someone

Sitting and reading

Watching TV

Sitting inactive in a public place

Lying down to rest in the afternoon

Sitting quietly after lunch without alcohol

In a car, while stopped for a few minutes in traffic

Part 1

Have you been told that you snore?

Yes

No

Does your family have a history of premature death in sleep?

Yes

No

Do you have Diabetes?

Yes

No

Have you ever been told you have Coronary Artery Disease?

Yes

No

Have you been told that you have high blood pressure?

Yes

No

Have you ever experienced an irregular heart beat?

Yes

No

Part 2

Are you taking opioid pain medications on a regular basis?

Yes

No

Have you ever been diagnosed with sleep apnea?

Yes

No

Do you awaken from sleep with chest pain or shortness of breath?

Yes

No

Has anyone said that you seem to stop breathing while sleeping?

Yes

No

Is your neck size larger than 15” (female) or 16.5’’ (male)?

Yes

No

Neck Size

Have you ever had a stroke?

Yes

No

Have you ever been told you have congestive heart failure?

Yes

No

Do you have or did you ever have atrial fibrillation?

Yes

No

Signature

Patient's Signature

Clear

Today's date

IN OFFICE USE ONLY

Are you a staff member?

Yes

No