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Insurance Form

Following form submission, you will be directed to pay the $99.00 physician interpretation fee.

Personal Demographics




Height (inches): BMI:
Insurance
Epworth Sleepiness Scale

Use the following scale to choose the most appropriate chance of your patient dozing for each situation
(0 = would never doze; 1 = slight chance of dozing; 2 = moderate chance of dozing; 3 = high chance of dozing)

Situation Chance of Dozing Off
0 1 2 3
Sitting and Reading
Watching TV
Sitting, inactive in a public place (theater or meeting)
As a passenger in a car for an hour without a break                
Lying 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
STOP-Bang Questionnaire

Please answer by checking “Yes” or “No” next to each of the below. Each Yes response is equivalent to 1 point. A score ≥3 may indicate excessive sleepiness and prompt consideration for medical attention.

 Yes   No 
Tired: Do you often feel Tired, Fatigued, or Sleepy during the daytime (such as falling asleep during driving or talking to someone)?  Yes   No 
Observed: Has any Observed you Stop Breathing or Choking/Gasping during your sleep?  Yes   No 
Pressure: Do you have or are being treated for High Blood Pressure?  Yes   No 
Age: >50 years old?  Yes   No 
Neck circumference: >16 inches?  Yes   No