WJMC - West Jefferson Medical Center

WJMC - West Jefferson Medical Center


WJMC Sleep Disorders Center Apnea Questionnaire Form

 
  First name Last name
  Your Name:
 

 

 
  Date of Birth:

 
  Height:  

 
  Weight:  

 
  Best number to reach you (Daytime)
  Contact Phone:

 
  Email Address:  
 
 



  Do you have a
  primary care
  doctor?
  Primary Care Doctor’s Name:

 
  This question is for marketing purposes only. All are welcome to fill out questionnaire.
  Are you a
  current patient
  at West Jeff?
   



S.T.O.P.

 
  SNORE: Do you snore loudly (louder than talking or loud enough to be heard through
      closed doors?
 
  TIRED: Do you often feel TIRED, fatigued or sleepy during the daytime?  
  OBSERVED: Has anyone observed you stop breathing during your sleep?  
  PRESSURE: Do you have or are you being treated for high blood pressure?  



B.A.N.G.
 
  BMI: Is your BMI more than 35?   View BMI Calculator  
  AGE: Are you over 50 years old?  
  NECK: Is your neck circumference greater than 17” (male) or 16” (female)?  
  GENDER: Are you a male?  

 


 

 
 
 

 



WJMC Pediatric Emergency