Sleep Health and Apnea Screening Survey

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Sleep Health and Apnea Screening Survey

Sleep Health and Apnea Screening Survey

24Questions

1
Are you referred by any doctor to take this assessment?* This field is required.
YESNO
2
Kindly key in your doctor's name here.
3
Name* This field is required.
Mr.
Mr.
Ms.
Mrs.
Mdm.
Dr.
Prefix
First Name
Last Name
4
Email* This field is required.
example@example.com
5
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
6
2. Do you often feel tired, fatigue, or sleepy during the day?* This field is required.
YESNO
7
3. Has anyone observed you stop breathing or choking/gasping during your sleep?* This field is required.
YESNO
8
4. Do you have or are you being treated for High Blood Pressure?* This field is required.
YESNO
9
Enter Height in Meters - For calculation of your Body Mass Index* This field is required.Eg. Weight is 1.7m, Enter 1.7
10
Enter Weight in KG - For calculation of your Body Mass Index* This field is required.Eg. Weight is 54kg, Enter 54
11
Your Body Mass Index is......* This field is required.
12
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
13
6. Are you above 50 years old?* This field is required.
YESNO
14
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
15
8. If you are male, please mark YES. If you are female, please mark NO.* This field is required.
YESNO
16
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
17
Do you drink alcohol?* This field is required.
More than 4 times a week
Less than 4 times a week
I don't drink at all
Used to drink but have stopped now
18
Do you smoke?* This field is required.
More than 4 times a week
Less than 4 times a week
I don't smoke at all
Used to smoke but have stopped now
19
Calculation
20
What is the Sleep Health Discovery Assessment?
21
Despite being at low risk of apnea, would you still be interested in the Sleep Health Discovery Assessment?
YESNO
22
Would you like to receive Sleep Health related Articles, Talk Invitations and Promotions from The Air Station?
YESNO
23
What is the Sleep Health Discovery Assessment?
24
If you are found to be at MODERATE to HIGH RISK of sleep apnea, you are encouraged to get a Home Sleep Study to find out more about your condition.
YESNO
25
Would you like more information on Home Sleep Study?
YESNO
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