Sleep Questionnaire - Express Medical Solutions

Personal Information

Name

First Name

Middle Name

Last Name

Date Of Birth
/ /

Age

Gender
MaleFemale

Phone Number

Email (used for confidential information)

Height

Weight

Neck Size

Do you snore loudly?
Louder than talking or loud enough to be heard through closed doors

YesNo

Do you often feel tired, fatigued, or sleepy during the daytime?

YesNo

Has anyone observed you stop breathing during sleep?

YesNo

Do you have (or are you being treated for) high blood pressure?

YesNo

Additional Comments