Sleep Apnea Screening

After taking this survey, your information will be sent to our sleep specialists and they will contact you within 3 business days to discuss your results and if necessary, schedule a sleep study.

PATIENT INFO / FIELDS WITH * REQUIRED
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ft. and inches.
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lbs.
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ARE YOU MALE OR FEMALE *
Male Female

WHAT IS YOUR NECK SIZE? *
Inches

DOCTOR'S INFORMATION


SCREENING QUESTIONS


Do you snore loudly (louder than talking or loud enough to be heard through closed doors)? *
Yes No

Do you have a history of heart disease? *
Yes No

Has anyone observed you stop breathing during your sleep? *
Yes No

Do you have or are you being treated for high blood pressure? *
Yes No

Do you have diabetes? *
Yes No

Do you have a small airway? *
Yes No

Do you have untreated hypothyroidism? *
Yes No

Do you have micronathia? *
Yes No

Do you have retrognathia? *
Yes No

(If female) Are you postmenopausal? *
Yes No

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

WHAT OUR PATIENTS ARE SAYING...
“My doc referred me to Aeroflow when I needed a sleep test. The service was exceptional! Aeroflow really cares about their customers.”
WHAT OUR PATIENTS ARE SAYING...
“When I call to order CPAP parts, I am always treated respectfully and kindly. I appreciate their service and care. I highly recommend them, to my friends and anyone!”
WHAT OUR PATIENTS ARE SAYING...
“I appreciate them calling me each month to ensure I don't forget to order supplies. I don't always remember, but they do!”
WHAT OUR PATIENTS ARE SAYING...
“My husband gets his sleep apnea CPAP supplies from Aeroflow. If we didn't like or trust them, we wouldn't put his health in their hands. They have done good for us.”