AZ Sleep Assessment

Sleep Apnea Screening Form

Patient Name(Required)

First Last

Patient Date of Birth(Required)

MM slash DD slash YYYY

Snoring?(Required)

Do you snore loudly (loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night)?

Yes

Tired?(Required)

Do you often feel tired, fatigued, or sleep during the daytime (such as falling asleep during driving or talking to someone)?

Yes

Observed?(Required)

Has anyone observed you stop breathing or choking/gasping during your sleep?

Yes

Pressure?(Required)

Do you have a history of high blood pressure?

Yes

Body Mass Index?

Calculate you body mass index (click the link below) and enter it here.

Age older than 50?(Required)

Are you older than 50 years old?

Yes

Neck Size Large? (Measured around Adams apple)(Required)

Is your shirt collar 16 inches / 40cm or larger?

Yes

Gender?(Required)

Are you a male?

Yes

Email(Required)

Enter Email Confirm Email

Phone(Required)

10245 E Via Linda Suite #226
Scottsdale, AZ 85258
602.638.2539

7200 W Bell Road C-3
Glendale, AZ 85308
602.638.2539

13203 N 103rd Ave # G1
Sun City, AZ 85351