Home
Offices
BOSTON
MIAMI
NEW YORK CITY
WASHINGTON, DC
CPAPs
Auto CPAP
Travel
Masks
Nasal Mask
Nasal Pillows
Full Face Mask
ACCESSORIES
CPAP Batteries
Cleaners & Mask Wipes
Humidifier Chambers
Power Supplies
Tubing
STEP: 1
PATIENT QUESTIONNAIRE
Thank you for choosing
eSNORE & SLEEP
for your Home Sleep Test. Please take a few minutes to fill out this questionnaire.
Patient Demographics
*
Indicates required field
Select One
*
Mr.
Mrs.
Ms.
Name
*
First
Last
D.O.B.
*
Mobile Number
*
Home Number
*
Gender
*
Male
Female
Email
*
Can we send you a text?
*
No
Yes
Yes, As the last option
Yes, It's prefered
Choose each method
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Your Health History
Height
*
Under 4'10"
4'10"
4'11"
5' 0"
5' 1"
5' 2"
5' 3"
5' 4"
5' 5"
5' 6"
5' 7"
5' 8"
5' 9"
5'10"
5'11"
6' 0"
6' 1"
6' 2"
6' 3"
6' 4"
Over 6' 4"
Approximate Weight
*
120 lbs
125 lbs
130 lbs
135 lbs
140 lbs
145 lbs
150 lbs
155 lbs
160 lbs
165 lbs
170 lbs
175 lbs
180 lbs
185 lbs
190 lbs
195 lbs
200 lbs
205 lbs
210 lbs
215 lbs
220 lbs
225 lbs
230 lbs
235 lbs
240 lbs
245 lbs
250 lbs
255 lbs
260 lbs
265 lbs
270 lbs
275 lbs
280 lbs
285 lbs
290 lbs
295 lbs
300 lbs
Over 300 lbs
Currently using CPAP?
*
Yes
No
Currently on Oxygen?
*
Yes
No
Check all symptoms that apply:
*
Daytime Sleepiness/Napping
Fatigue
Hypertension
Irritability/Moodiness
Morning Headached
Previous Diagnosis of OSA
Shift Work
Witnessed Apneic Events
Witnessed Choking/Gasping During Sleep
Witnessed Snoring
NONE
Check all situations that apply
*
Assessment of efficacy of CPAP/Any PAP Therapy
Assessment of efficacy of Oral Appliance Therapy
Assessment of efficacy of Surgery
Assessment of efficacy of other treatment
Re-evaluation of OSA is needed to continue therapy
Other
NONE
Other
*
Previously Diagnosed:
Choose Any
*
Atrial Fibrillation
Congestive Heart Failure
COPD
Coronary Artery Disease
Diabetes
GERD
Hypertension
Movement Disorder/Bruxism
Obestity
Seizure within the last 12 months
Stroke/TIA
OTHER
NONE
Please list Other Ailments (Type N/A if none)
*
Medications
*
Benzodiazepines
Narcotics
Other Hypnotics
N/A
Sleep Assesment
I have had a Sleep Study before
*
No
Tried, but could not complete it
Yes, less than 2 years ago
Yes, more than 2 years ago
I have tried CPAP before
*
Never
Tried, but could not tolerate it
I am currently using CPAP
I wake with dry mouth or throat
*
Never
Occasionally
Frequently
Every Day
I wake up in the middle of the night
*
Never
Occasionally
Frequently
Every Night
I usually wake up to urinate
*
Never
Once
Twice
Three or more times
At night, I usually wake up
*
Almost never
Once a night
Several times a night
More than 3 times a night
Epworth Sleepiness Scale:
Do you get sleepy, or doze off while sitting & reading?
*
Never doze off
Slight Chance of dozing
Moderate Chance of dozing
High Chance of dozing
Do you get sleepy, or doze off while watching TV?
*
Never would doze off
Slight Chance of dozing
Moderate Chance of dozing
High Chance of dozing
While sitting or inactive in a public place (meeting, theater)?
*
Never would doze off
Slight Chance of dozing
Moderate Chance of dozing
High Chance of dozing
As a passenger in a car for an hour without a break?
*
Never would doze off
Slight Chance of dozing
Moderate Chance of dozing
High Chance of dozing
Lying down to rest in the afternoon?
*
Never would doze off
Slight Chance of dozing
Moderate Chance of dozing
High Chance of dozing
Sitting and talking to someone?
*
Never would doze off
Slight Chance of dozing
Moderate Chance of dozing
High Chance of dozing
Sitting quietly after lunch without alcohol?
*
Never would doze off
Slight Chance of dozing
Moderate Chance of dozing
High Chance of dozing
In a car, while stopped for a few minutes at a traffic light?
*
Never would doze off
Slight Chance of dozing
Moderate Chance of dozing
High Chance of dozing
STEP 2:
Scheduling a call back from an
eSNORE & SLEEP
technician
Thank you for completing our questionnaire. A technician will contact you to review this questionnaire and discuss the next steps in the process.
Please indicate which day that you are available for a brief call, and choose a one hour window when the technician can contact you.
For example: (
Tomorrow
or
2 Days From Now
) and (
9:00 am
to
10:00 am
).
Best day to review this questionnaire?
*
Tomorrow
2 Days From Now
Best time to reach you on that day
*
8:00 AM till 9:00 AM ET
9:00 AM till 10:00 AM ET
10:00 AM till 11:00 AM ET
11:00 AM till 12:00 PM ET
12:00 PM till 1:00 PM ET
1:00 PM till 2:00 PM ET
2:00 PM till 3:00 PM ET
3:00 PM till 4:00 PM ET
4:00 PM till 5:00 PM ET
5:00 PM till 6:00 PM ET
Submit
Home
Offices
BOSTON
MIAMI
NEW YORK CITY
WASHINGTON, DC
CPAPs
Auto CPAP
Travel
Masks
Nasal Mask
Nasal Pillows
Full Face Mask
ACCESSORIES
CPAP Batteries
Cleaners & Mask Wipes
Humidifier Chambers
Power Supplies
Tubing