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.
3.   I have diabetes
4.   I have high blood pressure.
5.   I have had a stroke.
6.   I have heart problems or have had a heart attack.
7.   I often feel sleepy during the day.
8.   I suddenly wake up gasping for breath during the night.
9.   I have noticed my heart pounding or beating irregularly during the night
10. I awaken often during the night to urinate
11. I experience an aching or crawling sensation in my legs and move them often during the night.
12. I get morning headaches.
13. I have trouble at work due to sleepiness.
14. I have fallen asleep driving.

Name

Address (include city, state, zip code):

Phone:

Family Physician: 

Saint John's Sleep Lab will maintain this information as confidential.  You may wish to print a copy of the Quiz before pressing the Submit button.  Visit Saint John's Medical Supplies for CPAP and BIPAP equipment.