ISLEEPLOGO (002)

Sleep Apnea Screening Form

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Gender
Address

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