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National In-Network Providers

Fill out this short sleep apnea screener & be on your way to sleeping better!

Epworth Sleepiness Scale
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just 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 choose the most appropriate number for each situation.

* Indicates required field

Sitting and Reading? *

0 - Would never dose 1 - Slight chance of dozing 2 - Moderate chance of dozing 3 - High chance of dozing

Watching TV? *

0 - Would never doze 1 - Slight chance of dozing 2 - Moderate chance of dozing 3 - High chance of dozing

Sitting, inactive, in a public place (e.g., a theater or a meeting)? *

0 - Would never doze 1 - Slight chance of dozing 2 - Moderate chance of dozing 3 - High chance of dozing

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

0 - Would never doze 1 - Slight chance of dozing 2 - Moderate chance of dozing 3 - High chance of dozing

Lying down to rest in the afternoon when circumstances permit? *

0 - Would never doze 1 - Slight chance of dozing 2 - Moderate chance of dozing 3 - High chance of dozing

Sitting and talking with someone? *

0 - Would never doze 1 - Slight chance of dozing 2 - Moderate chance of dozing 3 - High chance of dozing

Sitting quietly after a lunch without alcohol? *

0 - Would never doze 1 - Slight chance of dozing 2 - Moderate chance of dozing 3 - High chance of dozing

In a car, while stopped for a few minutes in traffic? *

0 - Would never doze 1 - Slight chance of dozing 2 - Moderate chance of dozing 3 - High chance of dozing

Add your score to the Epworth (Patients with a higher than 8 score should consult with their MD about sleep apnea testing. *

5 simple questions for sleep apnea evaluation
Sleep apnea is a common breathing problem that can affect your sleep, health and quality of life. If you think you may suffer from sleep apnea, answer the ﬁve questions listed below.

Do you snore? *

Yes No

Are you excessively tired during the day? *

Yes No

Have you been told that you stop breathing during sleep? *

Yes No

Do you have a history of hypertension? *

Yes No

Is your neck size greater than 17 inches (male) or greater than 16 inches (female)? *

Yes No Unknown

Patient Information
Fill out your information and a sleep test prescription will be emailed to you to take to
your doctor to see if you qualify for a home sleep test to diagnose potential sleep apnea.

Name *

First

Last

Height (ft) *

Height (in) *

Weight (lbs) *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Primary Insurance Type *

Primary Insurance ID # *

Secondary Insurance Type *

Ordering Doctor/PCP *

MD Phone Number *

MD Fax Number *

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