Sleep Screen Page 2017-08-09T16:43:29+00:00

Aeroflow Industrial Sleep Test Questionnaire

Are you having trouble staying awake during your shift? Fatigue is real, and it’s dangerous. We’re here to make sure you are refreshed, healthy, and ready to get back on the road. Fill out this simple form to get started on the path to better health — all it takes is a few bits of information from you, and we handle the rest.

After submitting this form, your dedicated sleep specialist will get in touch to discuss your options.

From there…

  • We ship (free) the sleep test directly to your door, whether at home or on the road
  • It takes 1-2 nights to complete the test
  • You ship the test back in the provided free shipping package
  • Our board-certified sleep physician reviews data for obstructive sleep apnea
  • You will get started on a treatment program, or be cleared to get back on the road

It’s that easy!


PATIENT INFO / FIELDS WITH * REQUIRED
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SCREENING QUESTIONS

Do you snore on most nights (more than 3 times / week)? *
Yes No

Is your snoring loud?
(Can it be heard through a wall or door)? *
Yes No

Has it ever been reported that you stop breathing or gasp during sleep? *
Yes No

Neck Size *
Less than 17 Inches (Male) or Less than 16 inches (Female)
More than 17 inches (Male) or more than 17 inches (Female)

Have you had, or are you currently being treated for, high blood pressure? *
Yes No

Do you occasionally doze or fall asleep during the day when you are not busy or active? -or-
Do you occasionally doze or fall asleep during the day when you are driving or stopped at a light? *
Yes No

I authorize Aeroflow Healthcare to contact me by phone and email. Aeroflow will not share or distribute this information. *