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Sleep Apnea Assessment

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Take Our Sleep Apnea Assessment

Sleep Apnea Assessment

This form determines the need for you to have a sleep test, which will evaluate if you have a sleep disorder. Sleep Disorders negatively affect your cardiovascular health and well being, but can be effectively treated.

Call Us or Complete the form below

Contact Request

First Name *

Last Name *

Phone *

Physicians Name *

Email *

Part 1

1. Have you ever been told you have congestive heart failure? *

YesNo

2. Have you ever been told you have Coronary Artery Disease? *

YesNo

3. Have you ever had a stroke? *

YesNo

4. Do you take three or more medications for high blood pressure? *

YesNo

5. Have you ever experienced irregular heart rythms (atrial fibrillation)?

YesNo

6. Have you ever been told you stop breathing at night? *

YesNo

Do you have diabetes? *

YesNo

Part 2

1. Have you been told that you snore loudly? *

YesNo

2. Do you awaken from sleep with chest pain or shortness of breath? *

YesNo

3. Does your family have a history of premature death in sleep?

YesNo

4. Is your neck size larger than 15.5" (female) or 17.0 "(male)? *

YesNo

5. Have you ever been diagnosed with Obstructive Sleep Apnea? *

YesNo

6. Are you currently being treated for Sleep Apnea?

YesNo

Are you using your apparatus every night?

Epworth Sleepiness Scale

How likely are you to doze off while doing the following activities? Please use the following scale: 0 = never, 1 = slight, 2 = moderate, 3 = high. Select one of the following numbers

Being a passenger in a motor vehicle for an hour or more *

0123

Sitting and talking to someone *

0123

Sitting and reading *

0123

Watching TV *

0123

Sitting inactive in a public place *

0123

Lying down to rest in the afternoon *

0123

Sitting quietly after lunch without alcohol

0123

In a car while stopped for a few minutes in traffic *

0123

248-827-1144

Sleep Apnea Assessment

Take Our Sleep Apnea Assessment

Sleep Apnea Assessment

Call Us or Complete the form below

Contact Request

#SleepApnea

The Journey to Improved Sleep Quality

Meet Our Doctors

Dr. Earl K. Bogrow

DDS, F-AGD, D-ABDSM

Dr. Jason Sherbel

DDS, MS, D-ABDSM

Sleep Apnea

Contact Us

Bogrow & Sherbel

248-827-1144

248-281-0369