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ISLEEPLOGO (002)

Sleep Apnea Referral Form

MM slash DD slash YYYY
Gender
Address

Do they SNORE loudly (louder than talking or loud enough to be heard through closed doors)?
Do they often feel TIRED, fatigued, or sleepy during daytime?
Has anyone OBSERVED you stop breathing during your sleep?
Do they have or are you being treated for high blood PRESSURE?
Do they have or are you being treated for DIABETES?

BMI more than 35kg/m2?
AGE over 50 years old?
NECK circumference > 16 inches (40cm)?
GENDER: Male?
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