* Mandatory Fields

Agents Info:

    *Name:      

     Agency: 

    *Phone #:      *Fax #: 

    *E-mail address: 

Client Info:

    *Name:    

    *DOB:       *Height?      *Weight?    

    *Sex?       Male Female

If your client has sleep apnea, please answer the following:

1. Please list date of  diagnosis?  

2. Was the sleep apnea diagnosed as:   Unknown Obstructive Central Mixed

3. How is the sleep apnea being treated?   None Observation alone Weight loss CPAP mask Surgery Other

           If other, please give details?  

4. Is your client on medications?   Unknown Yes No

            If yes, please give details:  

5. Please check if your client has had any of the following:

            Lung Disease?        Overweight?        Arrhythmia?      Depression?  

            Chest pain or coronary artery disease?  

6. Has your client smoked cigarettes in the last 12 months?    Unknown Yes No

7. Please note date of the most recent sleep study?  

If possible, either describe the result of the last sleep study:

8. Does your client have any other major health problems

    (ex. Cancer, etc.)?   Unknown Yes No

            If yes, please describe: