Give some important details about you -

Father/Husband's Name Age Sex Telephone Address: Height Weight Reffered By Occupation Present medical Complaints: H/O Any Past illness Current Medication Pov. Diagnosis Investigation Requested Select EEG NCS EMG VER BAER SSEP Sleep Study Usual Bedtime Wake-up Time Do you snore? Select Yes No Don't Know You snoring is? Select Slightly louder then breathing As loud as talking Louder than talking Very loud. Can be heard in abjacent room How often do you snore? Select Nearly every one 3-4 Times a week 1-2 times a week 1-2 times a month never or nearly never Has your snoring ever bothered other people?   Select Yes No Has anyone noticed that you quit breathing during your sleep?   Select Nearly every one 3-4 Times a week 1-2 times a week 1-2 times a month never or nearly never How often do you feel tired or fatigued after your sleep?   Select Nearly every one 3-4 Times a week 1-2 times a week 1-2 times a month never or nearly never During your waketime do you feel tired, fatigued or not up to par?   Select Nearly every one 3-4 Times a week 1-2 times a week 1-2 times a month never or nearly never Have you ever nodded off or fallen a sleep while driving a vehicle?   Select Yes No Do you have high blood pressure?   Select Yes No Don't Know Diabetes Select Yes No Heart Disease Select Yes No