Sleep Health and Apnea Screening Survey

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Sleep Health and Apnea Screening Survey

Sleep Health and Apnea Screening Survey

22Questions

1
Are you referred by any doctor to take this assessment?* This field is required
YESNO
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2
Kindly key in your doctor's name here.* This field is required(pls allow pop up link when prompted)
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3
Name* This field is required
Mr.
Prefix
First Name
Last Name
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4
Email* This field is required
example@example.com
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5
1. Do you snore loudly? * This field is requiredLoud enough to be heard through closed door, or your bed partner elbows you for snoring!
YESNO
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6
2. Do you often feel tired, fatigue, or sleepy during the day?* This field is required
YESNO
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7
3. Has anyone observed you stop breathing or choking/gasping during your sleep?* This field is required
YESNO
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8
4. Do you have or are you being treated for High Blood Pressure?* This field is required
YESNO
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9
Enter Height in Meters - For calculation of your Body Mass Index* This field is requiredEg. Weight is 1.7m, Enter 1.7
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10
Enter Weight in KG - For calculation of your Body Mass Index* This field is requiredEg. Weight is 54kg, Enter 54
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11
Your Body Mass Index is......* This field is required
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12
5. Is your Body Mass Index (BMI) more than 35?* This field is requiredBMI = Weight in KG / (Height in Meters x Height in Meters) eg. Wt (100kg) / (Ht 1.5m x 1.5m) = BMI 44
YESNO
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13
6. Are you above 50 years old?* This field is required
YESNO
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14
7. Is your neck size larger than 17 inches/43cm (male) or 16 inches/ 41cm (female)* This field is requiredMeasured around the adam's apple level
YESNO
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15
8. If you are male, please mark YES. If you are female, please mark NO.* This field is required
YESNO
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16
Past & Present Medical Conditions (Tick where applicable)Do you suffer from...
Heart Attack
Diabetes
Atrial Fibrillation/ Arrythmia
Stroke
High Cholesterol
Kidney Disease
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17
Do you drink alcohol?
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
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18
Do you smoke?
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
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19
Calculation
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20
What is the Sleep Health Discovery Assessment?
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21
Despite being at low risk of apnea, would you still be interested in the Sleep Health Discovery Assessment at 70% off? (Usual price: SGD500) * This field is required(pls allow pop up link if you choose yes.)
YESNO
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22
You are found to be at MODERATE to HIGH RISK of sleep apnea. Would you like to proceed to more in-depth sleep analysis using SLEEP HEALTH DISCOVERY ASSESSMENT? (pls allow pop up link if you choose yes.)* This field is requiredSource: Chung F et al. Anesthesiology 2008;108:812-‐21; Chung F et al. Br J Anaesth 2012, 108:768–75; Chung F et al. J Clin Sleep Med 2014;10:951-‐8.
YESNO
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23
Would you like to receive Sleep Health related Articles, Talk Invitations and Promotions from The Air Station?* This field is required
YESNO
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