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SAMPLE: Health Screening Report
Verified Home Sleep Test
Patient Demographics
*
Indicates required field
Name
*
First
Last
Gender
*
Male
Female
D.O.B.
*
Mobile Number
*
Home Number
*
Email
*
Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
Zip Code
*
Insurance Information
Insurance Company
*
Phone Number
*
Untitled
*
Untitled
*
Your Health History
Height
*
Under 4'10"
4'10"
4'11"
5' 0"
5' 1"
5' 2"
5' 3"
5' 4"
5' 5"
5' 6"
5' 7"
5' 8"
5' 9"
5'10"
5'11"
6' 0"
6' 1"
6' 2"
6' 3"
6' 4"
Over 6' 4"
Approximate Weight
*
120 lbs
125 lbs
130 lbs
135 lbs
140 lbs
145 lbs
150 lbs
155 lbs
160 lbs
165 lbs
170 lbs
175 lbs
180 lbs
185 lbs
190 lbs
195 lbs
200 lbs
205 lbs
210 lbs
215 lbs
220 lbs
225 lbs
230 lbs
235 lbs
240 lbs
245 lbs
250 lbs
255 lbs
260 lbs
265 lbs
270 lbs
275 lbs
280 lbs
285 lbs
290 lbs
295 lbs
300 lbs
Over 300 lbs
Please check if you have any of the following
*
High Blood Pressure
Heart Disease
Pulmonary Disease
Insomnia
Overweight
Diabetes
Frequent Urination at Night
Seizure Disorder
Other
NONE
Please describe any other ailments not listed (or type "none")
*
Please list any surgeries you may have had (or type "none")
*
Sleep Assesment
I have been told that I snore
*
Yes
No
Don't Know
I have had a Sleep Study before
*
No
Tried, but could not complete it
Yes, less than 2 years ago
Yes, more than 2 years ago
I have tried CPAP before
*
Never
Tried but could not tolerate it
Tried and want to own one
I am currently using CPAP
I wake up in the middle of the night
*
Never
Occasionally
Frequently
Every Night
I usually wake up to urinate
*
Never
Once
Twice
Three or more times
I wake with dry mouth or throat
*
Never
Occasionally
Frequently
Every Day
Epworth Sleepiness Scale:
Do you get sleepy, or doze off while sitting & reading?
*
Never doze off
Slight Chance of dozing
Moderate Chance of dozing
High Chance of dozing
Do you get sleepy, or doze off while watching TV?
*
Never would doze off
Slight Chance of dozing
Moderate Chance of dozing
High Chance of dozing
While sitting or inactive in a public place (meeting, theater)?
*
Never would doze off
Slight Chance of dozing
Moderate Chance of dozing
High Chance of dozing
As a passenger in a car for an hour without a break?
*
Never would doze off
Slight Chance of dozing
Moderate Chance of dozing
High Chance of dozing
Lying down to rest in the afternoon?
*
Never would doze off
Slight Chance of dozing
Moderate Chance of dozing
High Chance of dozing
Sitting and talking to someone?
*
Never would doze off
Slight Chance of dozing
Moderate Chance of dozing
High Chance of dozing
Sitting quietly after lunch without alcohol?
*
Never would doze off
Slight Chance of dozing
Moderate Chance of dozing
High Chance of dozing
In a car, while stopped for a few minutes at a traffic light?
*
Never would doze off
Slight Chance of dozing
Moderate Chance of dozing
High Chance of dozing
Submit