Sleep Apnea Risk Assessment Please leave this field empty. Contact (Optional) Name Phone Email Sex Female Male Neck Size (select) 12.0 12.5 13.0 13.5 14.0 14.5 15.0 15.5 16.0 16.5 17.0 17.5 18.0 18.5 19.0 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: If you would like to be contacted by our staff for further evaluation, please press the button below to submit your information.
