Name *

First Name

Last Name

Phone *

(###)

###

####

Have you ever been given a CPAP device? *

Yes

No

If you have been given a CPAP, do you use it nightly?

Yes

No

Are you comfortable with your CPAP and satisfied with its use?

Yes

No

Being a passenger in a motor vehicle for an hour or more *

0

1

2

3

Sitting and talking to someone *

0

1

2

3

Sitting and reading *

0

1

2

3

Watching TV *

0

1

2

3

Sitting inactive in a public place *

0

1

2

3

Lying down to rest in the afternoon *

0

1

2

3

Sitting quietly after lunch without alcohol *

0

1

2

3

In a car while stopped for a few minutes in traffic *

0

1

2

3

Have you been told that you snore? *

Yes

No

Does your family have a history of premature death in their sleep? *

Yes

No

Do you have diabetes? *

Yes

No

Have you ever been told you have coronary artery disease? *

Yes

No

Do you have high blood pressure? *

Yes

No

Have you experienced irregular heart rhythms? *

Yes

No

Have you ever been diagnosed with Sleep Apnea? *

Yes

No

Do you awake from sleep with chest pain or shortness of breath? *

Yes

No

Has anyone ever said that you seem to stop breathing while sleeping? *

Yes

No

Is your neck size larger than 15" (female) or 16.5" (male) *

Yes

No

Have you ever had a stroke? *

Yes

No

Have you ever been told you have congestive heart failure? *

Yes

No

Did you have or did you ever have atrial fibrillation? *

Yes

No