Contact (Optional)
Sex
Female
Male
Neck Size
Inches

Medical Conditions: Have you been diagnosed or treated for any of the following conditions?

Medical Condition Yes No
High Blood Pressure
Heart Disease
Diabetes
Stroke
Depression
Sleep Apnea
 

Epworth Sleepiness Scale: How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usualy way of life in recent times. Even if you have not done some of those things recently, try to work out how they would have affected you. Use the following scale to mark the most appropriate box for each situation.

 
Activity Would never doze Slight chance of dozing Moderate chance of dozing High chance of dozing
Sitting and Reading
Watching TV
Sitting, inactive, in a a public place (theater, meeting, etc)
As a passenter in a car for an hour without break
Laying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car, while stopped for a few minutes in traffic
 

Recent History: In the past month

 
Question Never 0-1 times/week 1-2 times/week 3-4 times/week 5-7 times/week
Have you snored or been told that you snored?
Do you wake up choking or gasping?
Have you been told that you stop breathing in your sleep?
Do you have problems keeping your legs still at night or need to move them to feel comfortable?

Risk Score:


 

Request Appointment

770-586-0300
Office Hours: Monday-Friday 8AM-5PM

If you have any questions please let us know. We look forward to hearing from you!