Pacific Sleep Care
Your Sleep Apnea and Snoring Professionals

Client Information Form

Male Female

Epworth Sleepiness Scale: Please indicate by a number, how likely are you to doze off or fall asleep in the following situations?

0 = never doze
2 = moderate chance of dozing
1 = slight chance of dozing
3 = high chance of dozing
Please click correct button 0 1 2 3
Sitting and reading
Lying down to rest in the afternoon
Watching TV
Sitting and Talking to someone
Sitting inactive in a public place
Sitting quietly after lunch without alcohol
As a passenger in a car for an hour without a break
In a car while stopped for a few minutes in traffic

Please check the following signs and symptoms, which are applicable to you:

Witnessed apneas (told that you appear to stop breathing during sleep)
Chronic daytime fatigue
Difficulty maintaining sleep
Feeling tired upon awakening

The results of this test may indicate that you are experiencing sleep apnea. At your request this information can be sent to your physician.

I hereby confirm that all of the above information is correct and complete, and authorize Pacific Sleep Care to release any part or all of this information to my physician(s). Pacific Sleep Care agrees to keep your information confidential.