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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?
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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.
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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?
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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
*
Humana
Medicare
Tricare
Aetna
Coventry
BC/BS
Medicare Advantage
Private Pay ($249)
United Healthcare
Medicaid (Private Pay Rate - $249)
Other
Primary Insurance ID #
*
Secondary Insurance Type
*
Ordering Doctor/PCP
*
MD Phone Number
*
MD Fax Number
*
Submit
Private Pay?
