Patient Screening Form

Tell us about your sleep

A few short, clinician-used screeners in one form. Answer the questions below and our team will review your results and follow up. Informational only — not a diagnosis.

Patient Screening Form

A few quick screeners, one short form

Fill in your details and answer the Health Quiz, Epworth Sleepiness Scale, and a short sleep history. We’ll review your results and follow up. Takes about five minutes.

Your details
Health Quiz

If you answer “yes” to two or more of these, it’s worth talking with us about a sleep test.

Do you snore?
Do you gasp or choke during sleep (witnessed or observed)?
Do you feel sleepy, tired, or fatigued during the day?
Do you have high blood pressure, or are you being treated for it?
Do you have, or are you being treated for, diabetes?
Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in each situation — in contrast to just feeling tired? 0 = would never doze · 1 = slight chance · 2 = moderate chance · 3 = high chance. A total of 9 or more may suggest a sleep problem.

Sitting and reading
Watching TV
Sitting, inactive in a public place (e.g. a 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 a lunch without alcohol
In a car, while stopped for a few minutes in traffic
Epworth total0
Sleep History
Have you ever been diagnosed with a sleep disorder?
Do you currently use a CPAP machine?
Do you use a CPAP less than 4 days a week?
Would you prefer an oral appliance?
Prefer to print and fill it out by hand? Download the same Patient Screening Form as a PDF and bring it to your visit.
Download the PDF

Looking for the STOP-BANG self-check? Take it on our Screening Tests page

Start Tonight

Ready to finally sleep well?

Take a two-minute screening or call our Stratford office — we’ll help you understand your risk and find a treatment you’ll actually stick with.

Take the Free Screening 475-988-3398

1825 Barnum Ave, Ste 301, Stratford, CT 06614  ·  Monday – Sunday · Appointments only