*NAME: ______________________________________________
*ADDRESS: __________________________________________
__________________________________________
__________________________________________
*PHONE: (______)____________________________ Home Work Cell
*DATE of BIRTH: _________________________ E-MAIL___________________________________
*Required

Guidelines:

• PRINT AND THEN FAX TO: 714 744-8541or
• Mail or deliver test to: St. Joseph Hospital Sleep Disorders Center, 1310 West Stewart Drive, Suite 403, Orange, CA 92868. For more information visit the St. Joseph Hospital Sleep Disorders Center or call (888) 766-7363.
• Legal Notice: This test is intended to provide educational information only. It is in no way intended as medical advice. Participants seeking personal medical advice regarding specific health issues are instructed to contact a physician.
  
  I have read and agree to the above.

________________________________________________________________
Signature

St. Joseph Hospital Sleep Disorders Center
1310 West Stewart Drive (Suite 403)
Orange, CA 92868

For more information visit the St. Joseph Hospital Sleep Disorders Center or call (888) 766-7363

SNORING AND SLEEP APNEA QUESTIONNAIRE

NAME: ______________________________________________

Do you wake frequently during the night and feel unrefreshed in the morning?	Yes No
Do you have difficulty staying awake during the day?	Yes No
Do you have diabetes, hypertension or another health problem that affects your sleep?	Yes No
Are you overweight? Do you find it difficult to lose weight?	Yes No
Do you wake up with a dry mouth, sore throat or headache in the morning?	Yes No
Do you have difficulty concentrating during the day?	Yes No
Do you need to take naps during the day?	Yes No
Does your snoring bother you or your spouse enough for you to consider treatment?	Yes No
Optional: __________ __________ ___________
Height Weight Collar Size
Please rate how likely you are to doze off or fall asleep in the following situations:
	Never ...Slight Chance... Moderate Chance.. High Chance
1. Sitting and reading………………………………………	..... .....................
2. Watching TV…………………………………………….	..... .....................
3. Sitting inactive in a public place………………………	..... .....................
4. As a car passenger for 1 hour without a break……..	..... .....................
5. Lying down to rest in the afternoon…………………..	..... .....................
6. Sitting & talking to someone………………………….	..... .....................
7. Sitting quietly after lunch without alcohol……………	..... .....................
8. In a car, while stopping for a few minutes in traffic…	..... .....................
If you checked YES too more than 3 boxes and HIGH CHANCE at least once you need a Sleep Study. For more information or to schedule a Sleep Evaluation call us @ (888) 766-7363.

St. Joseph Hospital Sleep Disorders Center
1310 West Stewart Drive (Suite 403)
Orange, CA 92868
For more information visit the St. Joseph Hospital Sleep Disorders Center or call (888) 766-7363