Sleep Apnea Test: Assessing Sleep Problems

Name

FirstLast

Phone

Email

Restless Sleep

Always
Frequent
Rare

Loud, heavy snoring

Always
Frequent
Rare

Daytime sleepiness

Always
Frequent
Rare

Decreased daytime alertness

Always
Frequent
Rare

Irritability, short temper

Always
Frequent
Rare

Morning headaches

Always
Frequent
Rare

Forgetfulness

Always
Frequent
Rare

Mood or behavior changes

Always
Frequent
Rare

Anxiety or depression

Always
Frequent
Rare

Decreased interest in sex

Always
Frequent
Rare

GENERAL MEDICAL HISTORY

Height

Weight (lbs)

Neck size

Excluding pregnancy, what has the range of most of your weight been over the past five years?

What change has there been over the past five years?

Please check below if you have had any previous treatment for the following

Are you currently using a CPAP device or have you used one in the past?

Yes
No

What is your occupation?

What is your work schedule? (Days, start / end times)

How long have you been on this schedule?

Which of these best describes the extent of physical labor your present job or lifestyle demands?

Low- Main job done at desk or sitting with little or no physical activity. Lifestyle with little physical activity (no regular exercise program & daily activities without much physical effort)
Moderate- Lifestyle or main activity of job involves moderate work (standing, reaching, walking etc.)
High- Lifestyle or main activity of job involves strenuous work (heavy equipment, loading, climbing, etc.)

EPWORTH SLEEPINESS SCALE

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 have not done some of these things recently, try to work out how they would have effected you.

Use the following scale to select the most appropriate number for each situation:

0 = I would never doze

1 = Slight chance of dozing

2 = Moderate chance of dozing

3 = Higher chance of dozing

Sitting and reading

Watching TV

Sitting inactive in a public place (e.g. theatre or meeting)

As a passenger in a car 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 traffic

Total

Are you bothered by sleepiness under other circumstances?

Yes
No

Please describe:

Have you ever been in a car accident due to falling asleep at the wheel?

Yes
No
Near-miss

Please describe:

Have you had any other types of accidents because of sleepiness?

Yes
No

Please describe:

I would like a scheduler from your office to contact me:

By Phone
By Email
I do not want to be contacted. I will contact you.

Do You Have Sleep Apnea?