ABCDEF
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Real Sleep Solutions Sleep Disorder Assessment
Analysis
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This form evaluates the need for you to have a sleep test. The sleep test will determine if you have a sleep disorder. Sleep disorders negatively affect your well-being, but can be treated effectively. Low Probability of Sleep Apnea
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Part 1 | Epworth Sleepiness Scale1Total Score: 2
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How likely are you to doze off while doing the following activities? Please use the following scale:
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0 = never, 1 = slight, 2 = moderate, 3 = high. You have a low probability of having breathing issues during your sleep or Sleep Apnea.
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Being a passenger in a motor vehicle for an hour or more0
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Sitting and talking to someone0
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Sitting and reading3
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Watching TV2
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Sitting inactive in a public place0
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Lying down to rest in the afternoon3
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Sitting quietly after lunch without alcohol3
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In a car, while stopped for a few minutes in traffic0
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Total ESS17
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Part 21
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Have you been told that you snore?Yes
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Does your family have a history of premature death in sleep?No
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Do you have diabetes?No
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Have you ever been told you have coronary artery disease?No
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Do you have high blood pressure?No
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Have you ever experienced irregular heart rhythms?Yes
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Part 30
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Have you ever been diagnosed with sleep apnea?No
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Do you awaken from sleep with chest pain or shortness of breath?No
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Has anyone said that you seem to stop breathing while sleeping?Yes
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Is your neck size larger than 15” (female) or 16.5’’ (male)No
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Have you ever had a stroke?No
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Have you ever been told you have congestive heart failure?No
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Do you have or did you ever have atrial fibrillation?No
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