Sleep Assessment Form

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.

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:


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

Sitting and talking to someone

Sitting and reading

Watching TV

Sitting inactive in a public place

Lying down to rest in the afternoon

Sitting quietly after lunch without alcohol

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



Form Completion

If Patient is a Minor

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