info@godasco.com

Serving Ohio and surrounding states!

Logo Sleep Screening Logo

First Name A value is required. Last Name A value is required.
Weight Pounds: Invalid format.
A value is required.Minimum number of characters not met.Exceeded maximum number of charac		 Age Years: Invalid format.Minimum number of characters not met.Exceeded maximum number of characters.A value is required.

Please make a selection.
Height Feet: A value is required.Invalid format.Minimum number of characters not met.Exceeded maximum number of characters.Inches: A value is required.Invalid format.Minimum number of characters not met.Exceeded maximum number of characters. Neck Size Inches: A value is required.Invalid format.Minimum number of characters not met.Exceeded maximum number of characters.
Date of Birth A value is required.Invalid format.
 Customer #

FILL IN ONE CIRCLE FOR EACH QUESTION - ANSWER ALL QUESTIONS

Have you been diagnosed or treated for any of the following conditions?
High Blood Pressure

Stroke

Heart Disease

Depression

Diabetes

Sleep Apnea

Lung Disease

Nasal Oxygen Use

Insomnia

Restless Leg Syndrome

Narcolepsy

Morning Headaches

Sleeping Medication

Pain Medication (eg. Vicodin, Oxycontin)


Epworth Sleepiness Scale: How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to mark the most appropriate box for each situation. (M.W. Johns, Sleep 1991)
0 = would never doze 1 = slight chance of dozing
2 = moderate chance of dozing 3 = high chance of dozing
Sitting and reading

Watching TV

Sitting, inactive, in a public place (theater, meeting, etc)

As a passenger in a car for an hour without a break

Lying down to rest in the afternoon when circumstances permit

sitting and talking to someone

Sitting quietly after lunch without alcohol

in a car, while stopped for a few minutes in traffic


Frequency 0-1 times/week 1-2 times/week 3-4 times/week 5-7 times/week
On average in the past month, how often have you snored or been told that you snored?

Do you wake up choking or gasping?

Have you been told that you stop breathing in your sleep?

Do you have problems keeping your legs still at night or need to move them to feel comfortable?

Please make a selection.

Email Address
A value is required.Invalid formaExceeded maximum number of characters.
 A value is required.Phone Number
A value is required.Invalid format.		  

 

Site Created by: Rob Davis