Sleep Solutions New Patient Form Name(Required) First Last Email(Required) Enter Email Confirm Email Phone(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Epworth Sleepiness ScaleFor each question, you will answer with a number representing the likelihood of a particular event happening. 0 = No chance of dozing 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozingSitting & Reading(Required)0 = No chance of dozing 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozingPlease enter a number from 0 to 3.Watching TV(Required)0 = No chance of dozing 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozingPlease enter a number from 0 to 3.Sitting inactive in a public place(Required)0 = No chance of dozing 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozingPlease enter a number from 0 to 3.As a car passenger for an hour without a break(Required)0 = No chance of dozing 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozingPlease enter a number from 0 to 3.Lying down in the afternoon to rest(Required)0 = No chance of dozing 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozingPlease enter a number from 0 to 3.Sitting & talking to someone(Required)0 = No chance of dozing 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozingPlease enter a number from 0 to 3.Sitting quietly after lunch without alcohol(Required)0 = No chance of dozing 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozingPlease enter a number from 0 to 3.In a car while stopped at a traffic light(Required)0 = No chance of dozing 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozingPlease enter a number from 0 to 3.Do you have other concerns?Please click the box for any other concerns you have. Frequent snoring Excessive Daytime Sleepiness (EDS) Difficulty falling asleep Waking up gasping/choking Morning headaches Neck or facial pain I have been told I stop breathing when I sleep Difficulty staying asleep Choking while sleeping Feeling tired in the morning Memory problems Nasal problems, difficulty breathing through the nose Irritability or mood swings Select AllRate your overall energy level(Required)On a scale of 1 - 10, with 1 being low and 10 being excellent.Please enter a number from 1 to 10.Rate your sleep quality(Required)On a scale of 1 - 10, with 1 being poor and 10 being excellent.Please enter a number from 1 to 10.Have you been told you snore?(Required) Yes No On average how many times a night do you wake up?(Required)On average how many hours of sleep do you get per night?(Required)How often do you have a headache in the morning?(Required) Never Rarely Sometimes Often Everyday NameThis field is for validation purposes and should be left unchanged.
