Sleep Apnea Evaluation Form

If you think you may be experiencing sleep apnea, take the first step to finding out for sure by filling out our sleep apnea evaluation form. With your permission, we will forward it to your physician to begin a conversation about what’s happening and what your options are.

Evaluation Form

First Name

Last Name

Phone

D.O.B (MM/DD/YYYY)

Sex Male Female

City

Family Doctor

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
TOTAL

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

	Snoring
	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.

Due to illness and COVID isolation requirements, there may be times when we have to have an unscheduled closure of a local office. Please check our Facebook page for daily updates.

More information!

#101 -15 Canada Ave

Duncan, BC V9L 1T3

1255B Cliffe Avenue

Courtenay, BC V9N 2K3

277 Evergreen Road

Campbell River, BC V9W 5Y4

#3-5144 Metral Drive

Nanaimo, BC V9T 2K8

Sleep Apnea Evaluation Form

Evaluation Form

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