Pulmonary & Sleep Medicine Center of Winder
Pulmonary & Sleep Medicine Center of Winder Georgia
Pulmonary & Sleep Medicine Center of Winder
30 Satellite Drive Suite 200
Winder, GA 30680
Phone: 770-586-0300
Fax: 770-586-0311
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I would like to Schedule an Appointment
Pulmonary Disease Treatment
Sleep Disorder Consultation Request
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Screening for Sleep Apnea Questionnaire
 
Please complete the form below. To submit your sleep study evaluation click SEND TO when you are finished. Thank you for your interest in Pulmonary and Sleep Specialists of Northeast Georgia.
Contact (Optional)
Name
Phone
Email
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:


 
Asthma
Chronic Bronchitis
Chronic Obstructive Pulmonary Disease (COPD)
Emphysema
Lung Cancer
PleurX Catheter Placement
Endoscopic Bronchial Ultrasound
Sleep Apnea
Restless Leg Syndrome
Insomnia
Narcolepsy
Sleep Lab CPAP Therapy
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Pulmonary and Sleep Medicine Center of Winder is a trade name of Pulmonary and Sleep Specialists of Northeast Georgia PC
30 Satellite Drive Suite 200 Winder, GA 30680 Phone: 770-586-0300 Fax: 770-586-0311