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:



  Best number to reach you (Daytime)
  Contact Phone:

  Email Address:  

  Do you have a
  primary care
  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?


  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?  

  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