Makesleepeasy.com
Sleep Apnea Screening
Name *
Email *
Email address to send results of screen.
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Gender assigned at birth
Height *
in inches
Weight *
in pounds
Neck Circumference *
In inches. Measured at Adam's Apple. Also known as collar size.
Snoring *
Do you snore loudly (loud enough to be heard through closed doors, or your bed partner elbows you for snoring at night)?
Fatigue *
Do you often feel tired, fatigued, or sleepy during the daytime (such as falling asleep during driving)?
Apneas *
Has anyone observed you stop breathing or choking/gasping during your sleep?
Blood pressure *
Do you have or are you being treated for high blood pressure?
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? (This refers to your usual way of life in recent times. Even if you haven’t done some of these things recently try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation: ) *
0 - Would never doze, 1 - slight chance of dozing, 2 - Moderate chance of dozing, 3 - High chance of dozing
0
1
2
3
Sitting and reading
Watching TV
Sitting inactive in a public place (theatre or meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in the traffic
Consent to communicate using the email you provide *
By signing below, you acknowledge your recognition and understanding of the inherent risks of communicating your health information via unencrypted email and hereby consent to receive such communications at email entered above despite those risks. . By checking theis box you agree to hold makesleepeasy.com and Advanced respiratory and Sleep Medicine, PLLC harmless for unauthorized use, disclosure, or access of your protected health information sent to the email address you provide.
Required
Do you want your results sent to a healthcare provider? *
Enter name and fax number for the healthcare provider and we will forward the results.
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