Bay Area Sleep Testing Form

DEMOGRAPHIC INFO

First Name*

Middle Name/Initial

Last Name*

Date of Birth*

Age*

Phone number*

Gender*

Male Female

Weight*

Height (ft)

Height (in)

Neck Size (in.)

BMI

Have you been diagnosed or treated for any of the following conditions?

EPWORTH SLEEPINESS SCALE FORM:

Instructions: Be as truthful as possible. Read the situation in the first column; select your response from the second column; enter that number in the third column.

0 = would never doze

1 = slight chance of dozing

2 = moderate chance of dozing

3 = high chance of dozing

Situation

Sitting and reading

Watching television

Sitting inactive in a public place (e.g., a theater or a meeting)

As a passenger in a car for an hour without a break

Lying down to rest in the afternoon when circumstances permit

Sitting and talking to someone

Sitting quietly after a lunch without alcohol

In a car, while stopped for a few minutes in traffic

	Frequency	0 - 1 times/week	1 - 2 times/week	>3 - 4 times/week	5 - 7 times/week
On average in the past month, how often have you snored or been told that you snored?	Never	Rarely	Sometimes	Frequently	Almost always
Do you wake up choking or gasping?	Never	Rarely	Sometimes	Frequently	Almost always
Have you been told that you stop breathing in your sleep or wake up choking or gasping?	Never	Rarely	Sometimes	Frequently	Almost always
Do you have problems keeping your legs still at night or need to move them to feel comfortable?	Never	Rarely	Sometimes	Frequently	Almost always

PATIENT SIGNATURE:

Reset Signature

Date: