Sleep Assessment Sleep Apnea Screener Take this online screener to help determine if you might have Obstructive Sleep Apnea. 92% accurate, and can be completed before any testing is done. Step 1 of 6 16% This is a screening form to determine the need for a home sleep test, to see if you have a sleep disorder. How you sleep can affect your quality of life, especially your cardiovascular health. Long term sleep apnea can negatively affect your well-being, can lead to heart arrythmias, increase your chance for diabetes as well as strokes. Sleep disorders CAN be treated effectively.Name* First Last DOB* Date Format: MM slash DD slash YYYY Phone*Email* Insurance InfoPhysician Name Have you ever been given a CPAP device?*YesNoIf you have been given any form of CPAP, do you use it nightly?YesNoWould you want other options to treat your Sleep Apnea?*YesNo Epworth Sleepiness Scale: Using the following numbered scale, how likely are you to doze off while doing the following activities? 0 = Never 1 = Slight 2 = Moderate 3 = High (Select one of the following numbers)Being a passenger in a motor vehicle for an hour or more :*0123Sitting and talking to someone :*0123Sitting and reading :*0123Watching TV :*0123Sitting inactive in a public place :*0123Lying down to rest in the afternoon :*0123Sitting quietly after lunch without alcohol :*0123In a car, while stopped for a few minutes in traffic :*0123 Have you been told that you snore?*YesNoDoes your family have a history of premature death in sleep?*YesNoDo you have diabetes?*YesNoHave you ever been told you have coronary artery disease?*YesNoDo you have high blood pressure?*YesNoHave you ever experienced irregular heart rhythms?*YesNo Have you ever been diagnosed with sleep apnea?*YesNoDo you awaken from sleep with chest pain or shortness of breath?*YesNoHas anyone said that you seem to stop breathing while sleeping?*YesNoIs your neck size larger than 15” (Female) or 16.5’’ (Male)?*YesNoNeck Size Have you ever had a stroke?*YesNoHave you ever been told you have congestive heart failure?*YesNoDo you have, or did you ever have atrial fibrillation?*YesNoAre you currently taking pain meds?*YesNo
