Do you snore?
YesNo

Has anyone noticed that you stop breathing when you're sleeping?
YesNo

During your waking time, do you feel tired, fatigued or not up to par?
YesNo

Have you ever nodded off or fallen asleep while driving a vehicle?
YesNo

Do you have a chance of dozing in these situations:

Sitting and reading?
YesNo

Sitting and talking?
YesNo

Watching television?
YesNo

Sitting inactive in a public place such as a theater or meeting?
YesNo

In a car while stopped in traffic?
YesNo

Do you have high blood pressure?
YesNo

....
ASSESSMENT
If you have answered YES to 2 or more of the questions above, then you are at high risk for a sleep disorder.
If you have answered YES to 1 question, you are at moderate risk of a sleep disorder.
....

Would you like a sleep specialist from Valley Sleep Center to contact you?
YesNo

Best time to call?
MorningAfternoonEvening

Which location do you prefer?
ChandlerGlendaleMesaPhoenixScottsdale

Name of Insurance Provider

Phone number of Insurance Provider

Subscriber ID #

Group Number

First and Last name:

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For IE, format is (YYYY-MM-DD)

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