Sleep Evaluation Form

Sleep Evaluation
The Profiler takes about 02 minutes - Please complete all the fields
Full Name*

First NameLast Name
E-mail*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date*

MonthDayYear
Sex*

MaleFemale
Insurance Name
Insurance Type
Insurance ID#
Insurance Group
BMI Calculator*
Do you snore*

YesNoDont know
Your Snoring is:*

Slightly louder than breathingAs loud as talkingLouder than talkingVery loudDoes not apply
How often do you Snore?*

Almost every day3-4 times a week1-2 times a weekNever or almost never
Does your Snoring bother other people?*

YesNo
Has anyone noticed that you quit breathing during your sleep?*
Are you tired after sleeping?*
Are you tired during wake time?*

Almost every day3-4 times a week1 time a monthNever or almost never
Have you ever nodded off or fallen asleep while driving?*

YesNo
If yes, how often does it occur?*

Almost every day3-4 times a week1-2 times a weekNever or almost never
Do you have high blood pressure?*

YesNoDont Know
Would you like a sleep disorder specialist to contact you if your test results are high?

YesNo
How did you hear about this test?
Additional Comments
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