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Address
[dco_address_gmaps address id:gmaddress]

Information

Height

Weight

Neck Circumference

BMI

Primary Care Physician

Physician's Name

Physician's Phone

Primary Insurance

Sleepiness Scale

Sitting and Reading
0 = no chance of dozing1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozing

Watching TV
0 = no chance of dozing1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozing

Sitting innactive in a public place (e.g. a theater or meeting)
0 = no chance of dozing1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozing

As a passenger in a car for an hour without a break
0 = no chance of dozing1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozing

Lying down to rest in the afternoon when circumstances permit
0 = no chance of dozing1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozing

Sitting and talking to someone
0 = no chance of dozing1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozing

Sitting quietly after lunch without alcohol
0 = no chance of dozing1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozing

In a car, while stopped for a few minutes in traffic
0 = no chance of dozing1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozing

Risk Factors (Check all that Apply)

SnoringDiabetesHypertensionDaytime SleepinessMorning HeadachesHeart DiseaseOverweight/ObesityObserved ApneaStrokeKidney DiseaseRestless Leg

Additional Information