SERVING RICHMOND AND SURROUNDING AREAS

SLEEP APNEA SCREENER

First Name *

Last Name *

Email *

Phone *

Are you a DOT driver or are you trying to get tested for work? *

Yes

Please answer the following questions by checking if answer YES. *

Do you snore?

Do you often feel tired, fatigued, or sleepy during daytime?

Has anyone observed that you stop breathing or choke or gasp during your sleep?

Do you have or are you being treated for High Blood Pressure?

Is your BMI above 24 (Females) or 27 (Males)?

Is your age over 50 years old?

Is your neck size larger than 15" (Females) or 16.5" (Males)?

Gender *

Female

Male

Prefer not to answer

Your Weight *

Your Height *

Feet
Inches

Premier Sleep Solutions of Richmond

Sarah Wilmer, DDS

27 Briggs Drive

Manakin-Sabot, VA 23103

(804) 784-2386