Take Our Sleep Assessment Patient Portal

1719 Mt Vernon Rd, Ste. A
Dunwoody, GA 30338

(770) 394-4310

Sleep Disorder Assessment

Untreated sleep apnea can have significant implications for your health and quality of life. Take the quiz below to find out if your sleep troubles are minimal or if they could equal a more serious issue.

Name

Phone Number

Email Address

Part 1

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

1. Being a passenger in a motor vehicle for an hour or more

0 1 2 3

2. Sitting and lying down to rest

0 1 2 3

3. Sitting and reading

0 1 2 3

4. Watching TV

0 1 2 3

5. Sitting inactive in a public place

0 1 2 3

6. Lying down to rest in the afternoon

0 1 2 3

7. Sitting quietly after lunch without alcohol

0 1 2 3

8. In a car, while stopped for a few minutes in traffic

0 1 2 3

Part 2

1. Have you been told that you snore?

Yes No

2. Does your family have a history of premature death?

Yes No

3. Do you have diabetes?

Yes No

4. Have you ever been told you have coronary artery disease?

Yes No

5. Do you have high blood pressure?

Yes No

6. Have you ever experienced irregular heart rhythms?

Yes No

Part 3

1. Have you ever been diagnosed with sleep apnea?

Yes No

2. Do you dream?

Yes No

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

Yes No

4. Has anyone said that you seem to stop breathing while sleeping?

Yes No

5. Have you ever had a stroke?

Yes No

6. Have you ever been told you have congestive heart failure?

Yes No

7. Do you have or did you ever have atrial fibrillation?

Yes No

8. Are you currently taking pain meds?

Yes No

9. Do you have a CPAP?

Yes No

10. Do you use a CPAP at least 4 hours every night?

Yes No

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