Sleep Assessment Form

Patient First Name

Patient Last Name

Birth Date

Email

Patient Phone

OK to leave message?

Yes No

Regular Physician’s Name

Physician Phone

Referred By

Please 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.

1. Have you ever been given a CPAP device?

Yes No

2. If you have been given any form of CPAP, do you use it nightly?

Yes No

3. Are you comfortable with your CPAP and satisfied with its use?

Yes No

If the answer is YES to all of the above questions, PLEASE STOP.

If your answer is NO to any of the above questions, please continue to the following questions:

EPWORTH SLEEPINESS SCALE

How likely are you to doze off while doing the following activities? Please use the following scale:

0 = I would never doze
1 = I have a slight chance of dozing
2 = I have a moderate chance of dozing
3 = I have a high chance of dozing

Being a passenger in a motor vehicle for an hour or more

Chance of Dozing

Sitting and talking to someone

Chance of Dozing

Sitting and reading

Chance of Dozing

Watching TV

Chance of Dozing

Sitting inactive in a public place

Chance of Dozing

Lying down to rest in the afternoon

Chance of Dozing

Sitting quietly after lunch without alcohol

Chance of Dozing

In a car, while stopped for a few minutes in traffic

Chance of Dozing

Total Score

PART 1

1. Have you been told that you snore?

Yes No

2. Does your family have a history of premature death in sleep?

Yes No

3. Do you have Diabetes?

Yes No

4. Have you ever been told you have Coronary Artery Disease?

Yes No

5. Have you been told that you have High Blood Pressure?

Yes No

6. Have you ever experienced an Irregular Heart Beat?

Yes No

PART 2

1. Are you taking opioid pain medications on a regular basis?

Yes No

2. Have you ever been diagnosed with Sleep Apnea?

Yes No

3. Do you awaken from sleep with chest pain or shortness of breath?

Yes No

4. Has anyone said that you seem to stop breathing while sleeping?

Yes No

5. Is your neck size larger than 15” (female) or 16.5” (male)?

Yes No

6. Have you ever had a stroke?

Yes No

7. Have you ever been told you have Congestive Heart Failure?

Yes No

8. Do you have or did you ever have Atrial Fibrillation?

Yes No

Form Completion

Signature of Patient, Parent or Guardian:

Clear

Clear

Date

If Patient is a Minor

Form signed by:

Relationship to Patient:

PART 1

PART 2

Form Completion

If Patient is a Minor

Please rotate your device.