Do I Need A Sleep Evaluation
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1Do I Need a Sleep Evaluation?
Name: ______________________
Address: _________________________________________________________
Height: __________________________
Weight: ______________________
Male
Age: ____________________________
Sex: _________________________
_____ Do you have trouble falling asleep?
_____ Do you have trouble staying asleep?
_____ Do you have a creepy, crawly feeling in your legs?
_____ Do you get a good night’s sleep and still feel tired during the day?
_____ Do you fight to stay awake during the day?
_____ Do you wake up with headaches?
_____ Do you need to take naps during the day?
_____ Have you been told you snore or have woken yourself up snoring?
_____ Has someone witnessed you stop breathing or struggling to breathe while
you were sleeping?
_____ Have you woken up from sleep to catch your breath?
If you answered Yes to any of these questions, you may benefit from a sleep study.
Please print out this sheet, with your answers, and take it with you to see your
physician.
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Parent category: Business