Sleep Apnea Evaluation Form

First Name

Last Name

Email Address

Phone Phone

D.O.B

Sex Sex Male Female

City

Family Physician

Do you Snore Loudly (loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night? Do you Snore Loudly (loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night? yes no

Do you often feel Tired, Fatigued, or Sleepy during the daytime (such as falling asleep during driving or talking to someone)? Do you often feel Tired, Fatigued, or Sleepy during the daytime (such as falling asleep during driving or talking to someone)? yes no

Has anyone Observed you Stop Breathing or Choking/Gasping during your sleep? Has anyone Observed you Stop Breathing or Choking/Gasping during your sleep? yes no

Do you have or are being treated for High Blood Pressure? Do you have or are being treated for High Blood Pressure? yes no

yes no

yes no

yes no

yes no

For General Population - Please check what relates to you: For General Population - Please check what relates to you: OSA - Low Risk: Yes to 0 - 2 questions OSA - Intermediate Risk: Yes to 3 - 4 questions OSA - high Risk: Yes to 5 - 8 questions or Yes to 2 or more of 4 STOP questions + male gender or Yes to 2 or more of 4 STOP questions + BMI over 35kg/m² or Yes to 2 or more of 4 STOP questions + neck circumference 16 inches / 40 cm

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).