Provided by Saint John's Sleep Lab 683-3156

  
Please complete this quiz.  We will give the information to your physician for consultation on whether further diagnostic testing is appropriate for you.  If you have experienced any of the following symptoms in the past year, place a check mark in the Yes column.  YES
1.   I've been told that I snore.
2.   I've been told that I stop breathing while I sleep, although I don't remember this when I wake up.
3.   I have high blood pressure.
4.   I have had a stroke.
5.   I have heart problems.
6.   I smoke cigarettes;  packs per day  
7.   My family and friends say they have noticed changes in my personality
8.   I have noticed my heart pounding or beating irregularly during the night.
9.   I awaken often during the night to urinate
10. I suddenly wake up gasping for breath during the night.
11. I experience an aching or crawling sensation in my legs and move them often during the night.
12. I have vivid dreams soon after falling asleep.
13. I am unable to move upon awakening.
14. I get morning headaches.
15. I feel sleepy during the day even though I slept through the night.
16. I have had trouble concentrating.
17. I have trouble at work due to sleepiness.
18. I have fallen asleep driving.
19. I have fallen asleep during physical effort.
20. I fall asleep frequently during the day.
   
     Height     Weight   Age  
     Would you like the Sleep Lab to forward this information to your physician?
     Would you like to receive a call from a Sleep Lab staff person?

Name

Address (include city, state, zip code):

Phone:

Family Physician: 


In most browsers, you can right click on this page and "send as email to a friend."  Send to sleeplab@sjhsnet.org. You also may print the page and mail to Sleep lab, 2015 Jackson St., Anderson, IN 46016.  Visit Saint John's Medical Supplies for CPAP and BIPAP equipment.