Adult Sleep Eval
Name:
Email:


Please check any of the following you may have:








Please check Yes or No to the following questions?

Do you snore or have been told that you snore?
Do you often feel tired, fatigued, or sleepy during the daytime?
Has anyone observed you stop breathing or gasp for air during your sleep?
Do you have or are you being treated for high blood pressure?



If you answered Yes to 2 or more of the above, please continue:

Sleepiness Scale - which applies Never Doze Off Slight Chance Moderate Chance High Chance
Do you get sleepy, or doze off, while sitting and reading?
Do you get sleepy, or doze off, while watching TV?
While sitting or inactive in a public place?
As a passenger in a car for an hour without a break?
Lying down to rest in the afternoon?
Sitting and talking to someone?
Sitting quietly after lunch without alcohol?
In a car, while stopped for a few minutes at the traffic light?

Total Score:

Have you ever been diagnosed with Sleep Apnea?
Are you currently using CPAP? (or any other apnea/snoring device)
Are you currently taking any sleeping aids (prescribed or OTC)?
Are you currently taking any prescribed narcotic medication?

 
 

Untreated Sleep Disorders are related to many health and financial complications: *Diabetes *Premature death *5Xthe risk of heart attack *2X the risk of stroke *Weight gain *6X the risk of a serious automobile accident *Increased risk of cancer *Hypertension *Depression *Erectile dysfunction *Daytime fatigue *ADHD *GERD *Decreased job performance *RLSLPLM *Increased cost of healthcare *Chronic/migraine headaches *Post-surgical complications/death *Chronic pain *Weakened immune system *Renal failure *Heart disease