Home Sleep Apnea Test Intake
Patient Information
Full Name
Date of Birth
Phone Number
Email
Address
Referring Provider
Provider Name
Provider Phone
Medical History
Relevant Past Medical History
Sleep Apnea Symptoms
Check all that apply:
Snoring
Gasping for air at night
Pauses in breathing during sleep
Daytime sleepiness or fatigue
Difficulty staying asleep
Other
Medical Devices
Do you use any of the following?
Home Oxygen
CPAP/BiPAP
Pacemaker
None
Current Medications
Notes or Additional Concerns