CPAP Therapy Sleep Study Intake Form
Personal Information
Full Name
Date of Birth
Gender
Male
Female
Other
Prefer not to say
Phone Number
Email Address
Address
Medical Information
Height
Weight
Current Medical Conditions
Current Medications
Allergies
Smoker
No
Yes
Former
Sleep History
Referring Physician
Describe Your Sleep Symptoms
How long have you had these symptoms?
Previous Sleep Studies?
No
Yes
Previous CPAP Use?
No
Yes
Additional Notes