Sleep Apnea Assessment

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.   

 

 
Part 1
Part 2
 
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