Sleep Disorder Evaluation Form

Note that this form does not constitute a doctor-patient relationship and cannot be used to actually diagnose sleep apnea. When you complete this form, someone from our office will contact you with the appropriate next steps toward an actual sleep apnea diagnosis.

First Name:

Last Name:

Email:

Phone:

Age:

Height:

Weight:

Gender:

Have you ever had an evaluation
at a Sleep Center?

CPAP (Continuous Positive Airway Pressure) Intolerance

Have you tried CPAP?

Other Therapy Attempts

What other therapies have you had for breathing disorders?
(weight-loss attempts, smoking cessation for at least one month, surgeries, etc.)

Do You Snore?

The Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations?

Sitting and reading

Watching TV

Sitting in a public place (e.g.: theatre, meeting or church)

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 lunch without alcohol

In a car, while stopped for a few minutes in traffic

To optimize your health and get answers to your snoring-, sleep apnea-, insomnia-, and all sleep disorder questions, your search is over.

Contact Dr. Mark T. Weiser today at (805) 754.3653 for the Santa Barbara location or(310) 237.6620 for the Los Angeles location.