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Sleep Center Screening and Order Form

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Sleep Center Screening and Order Form

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Patient Name*

First Last

Date of Birth*

MM slash DD slash YYYY

Phone Number

Primary Care Physician

We have developed this self-scoring questionnaire as a guide to help identify sleep disorder breathing problems. Please check the appropriate box if you have experience any of the symptom(s) on a regular basis. Your doctor will discuss these results with you during your follow up visit to his/her office.

Symptoms of Sleep Apnea

1. I have been told I snore

2. I have been told that I stop breathing when I sleep, although I may have no recollection of this.

3. I am always sleepy during the day even when I have slept throughout the night.

4. I have high blood pressure.

5. I have been told that I sleep restlessly. I am always "tossing" and "turning"

6. I tend to sweat excessively during my sleep.

7. I frequently awaken with a headache in the morning.

8. I tend to fall asleep during inappropriate times.

9. Others and/or I have noticed a change in my personality.

10. I am overweight.

Current weight

Height

SCORING: If you have Marked 3 or More Boxes, you show Symptoms of Sleep Apnea, a life threatening sleep disorder that causes you to stop breathing during your sleep.

Comments

This field is for validation purposes and should be left unchanged.

Contact Information

184 Estate Diamond RubyChristiansted00820US Virgin Islands

https://www.acutealternative.com/health@acutealternative.com1-340-772-2883

Doctors

Dr. Lyn A. Campbell
Dr. Roy Z. Arcamo
Dr. Ramesh B. Lakhram
PA-C. Jason A. Snow

New Patient Intake

If you are a new to Acute Medical and desiring to be a patient, please complete our patient intake forms by clicking HERE.

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