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
0 = never
1 = slight
2 = moderate
3 = high
No elements found. Consider changing the search query.
List is empty.
Sitting and talking to someone
0 = never
1 = slight
2 = moderate
3 = high
No elements found. Consider changing the search query.
List is empty.
Sitting and reading
0 = never
1 = slight
2 = moderate
3 = high
No elements found. Consider changing the search query.
List is empty.
Watching TV
0 = never
1 = slight
2 = moderate
3 = high
No elements found. Consider changing the search query.
List is empty.
Sitting inactive in a public place
0 = never
1 = slight
2 = moderate
3 = high
No elements found. Consider changing the search query.
List is empty.
Lying down to rest in the afternoon
0 = never
1 = slight
2 = moderate
3 = high
No elements found. Consider changing the search query.
List is empty.
Sitting quietly after lunch without alcohol
0 = never
1 = slight
2 = moderate
3 = high
No elements found. Consider changing the search query.
List is empty.
In a car, while stopped for a few minutes in traffic
0 = never
1 = slight
2 = moderate
3 = high
No elements found. Consider changing the search query.
List is empty.
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