Sleep Apnea Test Total Care Home Medical Tyler, TX (866) 858-3300

Sleep Apnea Test Email * First Name * Last Name * Phone * Height (inches) (if 5' 10" you would enter 70 inches) Weight (pounds) Do you snore? How loud is your snoring? How frequently do you snore? Does your snoring bother other people? How often have your breathing pauses been noticed? Are you tired after sleeping? Are you tired during waketime? How often do you nod off or fall asleep while driving? Do you have high blood pressure?

How likely are you to doze off or fall asleep in the following situations. This is in contrast to simply feeling tired? This refers to your present and recent usual experience. Use the following scale to choose the most appropriate selection for each situation.

Situation: Sitting and Reading Situation: Watching TV Situation: Sitting inactive in a public place (ie- theaters, meetings) Situation: As a passenger in a car for an hour without a break Situation: Lying down to rest in the afternoon when possible Situation: Sitting and talking to someone Situation: Sitting quietly after lunch without alcohol Situation: In a car while stopped for a few minutes in traffic