Sleep Health and Apnea Screening Survey

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Sleep Health Screening Survey

Sleep Health Screening Survey

Take this Survey to check if you are at risk of sleep apnea!

19Questions

1
How did you learn about us?* This field is required.
Doctor's recommendation
Online/ Google Search
Facebook/Instagram
Other Events/ Advertisements
Friends & Family
2
Are you referred by any doctor to take this assessment?* This field is required.
YESNO
3
Kindly key in your doctor's name here.
4
Name* This field is required.
Mr.
Mr.
Ms.
Mrs.
Mdm.
Dr.
Prefix
First Name
Last Name
5
Email* This field is required.A copy of your responses will be sent.
example@example.com
6
1. Do you snore loudly?* This field is required.Loud enough to be heard through closed door, or your bed partner elbows you for snoring!
YESNO
7
2. Do you often feel tired, fatigue, or sleepy during the day?* This field is required.
YESNO
8
3. Has anyone observed you stop breathing or choking/gasping during your sleep?* This field is required.
YESNO
9
4. Do you have or are you being treated for High Blood Pressure?* This field is required.
YESNO
10
Enter Height in Meters - For calculation of your Body Mass Index* This field is required.Eg. Height is 1.7m, Enter 1.7
11
Enter Weight in KG - For calculation of your Body Mass Index* This field is required.Eg. Weight is 54kg, Enter 54
12
Your Body Mass Index is......* This field is required.
13
5. Is your Body Mass Index (BMI) more than 35?* This field is required.BMI = Weight in KG / (Height in Meters x Height in Meters) eg. Wt (100kg) / (Ht 1.5m x 1.5m) = BMI 44
YESNO
14
6. Are you above 50 years old?* This field is required.
YESNO
15
7. Is your neck size larger than 17 inches/43cm (male) or 16 inches/ 41cm (female)* This field is required.Measured around the adam's apple level
YESNO
16
8. If you are male, please mark YES. If you are female, please mark NO.* This field is required.
YESNO
17
Past & Present Medical Conditions (Tick where applicable)* This field is required.Do you suffer from...
Heart Attack
Diabetes
Atrial Fibrillation/ Arrythmia
Stroke
High Cholesterol
Kidney Disease
Not Applicable
18
Calculation
19
YOU ARE AT LOW RISK OF SLEEP APNEA! Would you like to receive Sleep Health related Articles, Talk Invitations and Promotions from The Air Station?By submitting YES, you will consent to The Air Station sending you information on sleep health via your email.
YESNO
20
YOU ARE AT MODERATE TO HIGH RISK OF SLEEP APNEA. A Home Sleep Study might be able to diagnose your sleep condition further. Would you like more information on Home Sleep Study?* This field is required.By submitting YES, you will consent to The Air Station sending you emails on sleep health information.
YESNO
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