* Denotes required fields

Patient Information

* Do you feel sleepy or have "sleep attacks" during the day?
* Do you have trouble concentrating during the day?
* Do you awaken during the night?
* Do you awaken more than once?
* Do you awaken too early in the morning?
* Do you feel refreshed in the AM?
* Do you have restless sleep?
* Do you fall asleep driving?
* Do you snore?
* Does your sleep partner say that you seem to stop breathing repeatedly during the night?
Please indicate the likelihood that you would fall asleep in the following situations (Scale of 0-3). This refers to your usual way of life in recent times. Use the following scale to choose the most appropriate number for each situation:

0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

Please fax an order and office notes pertaining to the sleep study to 701.780.1908. If you have any questions, please call the sleep lab at 701.780.5484.