28411 Northwestern Highway #230, Southfield, MI 48034 248-827-1144

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Sleep Apnea Assessment — duplicate-consumer51

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Sleep Apnea Assessment — duplicate-consumer51

Sleep Apnea Test

This form determines the need for you to have a sleep test, which will evaluate if you have a sleep disorder. Sleep Disorders negatively affect your cardiovascular health and well being, but can be effectively treated.

First Name *

Last Name *

Phone *

Physicians Name *

Email *

Part 1

1. Have you ever been told you have congestive heart failure?

YesNo

2. Have you ever been told you have Coronary Artery Disease?

YesNo

3. Have you ever had a stroke?

YesNo

4. Do you take three or more medications for high blood pressure?

YesNo

5. Have you ever experienced irregular heart rythms (atrial fibrillation)?

YesNo

6. Have you ever been told you stop breathing at night?

YesNo

Do you have diabetes?

YesNo

Part 2

1. Have you been told that you snore loudly?

YesNo

2. Do you awaken from sleep with chest pain or shortness of breath?

YesNo

3. Does your family have a history of premature death in sleep?

YesNo

4. Is your neck size larger than 15.5" (female) or 17.0 "(male)?

YesNo

5. Have you ever been diagnosed with Obstructive Sleep Apnea?

YesNo

6. Are you currently being treated for Sleep Apnea?

YesNo

Are you using your apparatus every night?

Epworth Sleepiness Scale

How likely are you to doze off while doing the following activities? Please use the following scale: 0 = never, 1 = slight, 2 = moderate, 3 = high. Select one of the following numbers

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

0123

Sitting and talking to someone

0123

Sitting and reading

0123

Watching TV

0123

Sitting inactive in a public place

0123

Lying down to rest in the afternoon

0123

Sitting quietly after lunch without alcohol

0123

In a car while stopped for a few minutes in traffic

012

Meet Dr. Bogrow

Dr. Bogrow has been serving his patients in Southfield since 1981. Having suffered from sleep apnea himself, Dr. Bogrow truly understands how his patients feel.

Useful links

About Sleep Apnea
Snoring & Sleep Apnea
Sleep Apnea Symptoms & Your Health
Sleep Apnea & Your Relationship
Sleep Apnea & ADHD
Treatment Options

Contact Us

28411 Northwestern Highway #230,
Southfield, MI 48034
Call: 248-827-1144
Fax: 248-281-0369