New Patient Sleep Apnea Questionnaire





 



New Patient Sleep Apnea Questionnaire

Please complete the following fields

 













Employer

Date of Birth

Gender

Height (inches)

Weight (lbs)

BMI:0

Have You Been Diagnosed with COPD?

Do you currently use supplemental Oxygen?

Have you been diagnosed with Congestive Heart Failure?

Have you been diagnosed with Atrial Fibrillation?

Have you been diagnosed with any Pulmonary Conditions?]

Have you been diagnosed with Coronary Artery Disease?

Have you been diagnosed with any Cardiac Arrhythmias?

Have you been diagnosed with Diabetes?

Have you been diagnosed with Rheumatoid Arthritis?

Have you been diagnosed with Hypothyroidism?

Have you been diagnosed with Micrognathia or Retrognathia?

Have you been diagnosed with Post Menopause?

Have you been diagnosed with a Small Airway?

Do you currently Smoke?

Do you have any Flu-like Symptoms?

Have you had a Fever Above 100F in Past 14 Days?

Have you had any Respiratory Symptoms Past 14 Days?

Do you have any of the Following? Hold CTRL to select multiple

What is your Neck Size (in.)?

Have you ever been treated for High Blood Pressure?

Do you often feel Tired or Fatigued

So you Snore?

Have you eve been told that you stop breathing at night?

Is your BMI more than 35kg/m2?