Sleep Disorder Evaluation

Have you ever had an evaluation at a sleep center?

Yes No

CPAP (Continous Positive Airway Pressure) Intolerance

Have you attempted treatment with a CPAP device, but could not tolerate it?

Yes No

I could not tolerate the CPAP device due to:

Mask leaks I was unable to get the mask to fit properly Discomfort caused by the straps and headgear Disturbed or interrupted sleep caused by the presence of the device Noise from the device disturbing my sleep and/or bed partner's sleep CPAP restricted movements during sleep CPAP does not seem to be effective Pressure on the upper lip causing tooth related problems A latex allergy Claustrophobic associations An unconscious need to remove the CPAP apparatus at night

Other Therapy Attempts

What other therapies have you had for breathing disorders?
(weight-loss attempts, smoking cessation for at least one month, surgeries, etc.)

Do you snore?

The Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations?

Sitting and reading

Watching TV

Sitting in a public place (e.g.: theatre, meeting or church)

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

Laying down to rest in the afternoon when circumstances permit

Sitting and talking to someone

Sitting quietly after lunch without alcohol

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

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