Sleep Screen Page – Internal 2017-07-03T14:18:16+00:00

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. *