Sleep Disorder Evaluation

Name:

Email:

Phone:

Age:

Height:

Weight:

Gender:

Have you ever had an evaluation at a Sleep Center?

Yes No

Sleep Center Name:

Location:

Sleep Study Date:

CPAP (Continuous Positive Airway Pressure) Intolerance

If you have attempted treatment with a CPAP device, but could not tolerate it, please fill in this section.

I could not tolerate the CPAP device due to:

mask leaks
I was unable to get the mask to fit properly
discomfort caused by the straps and headgear
disturbed or interrupted sleep caused by the presence of the device
noise from the device disturbing my sleep and/or bed partner's sleep
CPAP restricted movements during sleep
CPAP does not seem to be effective
pressure on the upper lip causing tooth related problems
a latex allergy
claustrophobic associations
an unconscious need to remove the CPAP apparatus at night

Other:

Other Therapy Attempts

What other therapies have you had for breathing disorders?
(weight-loss attempts, smoking cessation for at least one month, surgeries, etc.)

Do You Snore?

If you do, please answer these questions:

Do you snore?

If you snore:

How loud do you snore?

How often do you snore?

Does your snoring bother other people?

Has anyone noticed that you quit breathing during your sleep?

How often do you feel tired or fatigued after your sleep?

During your waketime, do you feel tired, or not up to par?

Have you ever nodded off or fallen asleep while driving a vehicle?

If yes, how often does it occur?

Do you have high blood presssure?

Sleepiness Quiz

How likely are you to doze off or fall asleep in the following situations?

Sitting and reading

Watching TV

Sitting in a public place (e.g.: theatre, meeting or church)

As a passenger in a car for an hour without a break

Lying 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