Adult Sleep Eval
Please check any of the following you may have:
Please check Yes or No to the following questions?
Do you snore or have been told that you snore?
|
|
Do you often feel tired, fatigued, or sleepy during the daytime?
|
|
Has anyone observed you stop breathing or gasp for air during your sleep?
|
|
Do you have or are you being treated for high blood pressure?
|
|
If you answered Yes to 2 or more of the above, please continue:
Sleepiness Scale - which applies |
Never Doze Off |
Slight Chance |
Moderate Chance |
High Chance |
Do you get sleepy, or doze off, while sitting and reading? |
|
Do you get sleepy, or doze off, while watching TV? |
|
While sitting or inactive in a public place? |
|
As a passenger in a car for an hour without a break? |
|
Lying down to rest in the afternoon? |
|
Sitting and talking to someone? |
|
Sitting quietly after lunch without alcohol? |
|
In a car, while stopped for a few minutes at the traffic light? |
|
Have you ever been diagnosed with Sleep Apnea?
|
|
Are you currently using CPAP? (or any other apnea/snoring device)
|
|
Are you currently taking any sleeping aids (prescribed or OTC)?
|
|
Are you currently taking any prescribed narcotic medication?
|
|
Untreated Sleep Disorders are related to many health and financial complications: *Diabetes *Premature death *5Xthe risk of heart attack *2X the risk of stroke *Weight gain *6X the risk of a serious automobile accident *Increased risk of cancer *Hypertension *Depression *Erectile dysfunction *Daytime fatigue *ADHD *GERD *Decreased job performance *RLSLPLM *Increased cost of healthcare *Chronic/migraine headaches *Post-surgical complications/death *Chronic pain *Weakened immune system *Renal failure *Heart disease