Make an Appointment

Full Name (required)

Your Email (required)

Your Phone (required)

Address

Information

Height

Weight

Neck Circumference

BMI

Primary Care Physician

Physician's Name

Physician's Phone

Primary Insurance

Sleepiness Scale

Sitting and Reading
0 = no chance of dozing1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozing

Watching TV
0 = no chance of dozing1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozing

Sitting innactive in a public place (e.g. a theater or meeting)
0 = no chance of dozing1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozing

As a passenger in a car for an hour without a break
0 = no chance of dozing1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozing

Lying down to rest in the afternoon when circumstances permit
0 = no chance of dozing1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozing

Sitting and talking to someone
0 = no chance of dozing1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozing

Sitting quietly after lunch without alcohol
0 = no chance of dozing1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozing

In a car, while stopped for a few minutes in traffic
0 = no chance of dozing1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozing

Risk Factors (Check all that Apply)

SnoringDiabetesHypertensionDaytime SleepinessMorning HeadachesHeart DiseaseOverweight/ObesityObserved ApneaStrokeKidney DiseaseRestless Leg

Additional Information