Home Screening & Home Testing

Sleep Well Centers Patient Profile
for Sleep Screening

You must complete both the Patient Profile and Epworth Sleepiness Scale

Name First Last
Date of Birth
Height
Weight
Address (screen unit should be shipped to)
Street Address

Address Line 2

City

Postal / Zip Code

State
Email
Home Phone
Cell Phone
Primary Care Physician
Epworth Sleepiness Scale

The Epworth Sleepiness Scale is a questionnaire designed to evaluate levels of excessive sleepiness. This test is a standardized screening tool used extensively by the American Association of Sleep Medicine (AASM) that will help you measure your general level of sleepiness. It ask you to rate the chances that you would doze off or fall asleep during different routine situations. Answers to the questions are rated as follows: Use the following scale to choose the most appropriate number for each situation:
0 = would never doze or sleep
1 = slight chance of dozing or sleeping
2 = moderate chance of dozing or sleeping
3 = high chance of dozing or sleeping
Situation: Sitting and reading

Chance of dozing or sleeping
Situation: Sitting inactive in a public place

Chance of Dozing or Sleeping
Situation: Being a passenger in a motor vehicle for an hour or more

Chance of dozing or sleeping
Situation: Lying down in the afternoon

Chance of dozing or sleeping
Situation: Sitting and talking to someone

Chance of dozing or sleeping
Situation: Sitting quietly after lunch (no alcohol)

Chance of dozing or sleeping
Situation: Stopped for a few minutes in traffic while driving

Chance of dozing or sleeping
Total score (add the scores up)(This is your Epworth score)
I agree that my physician has recommended a home sleep screening to help determine if I might suffer from a sleep disorder. I will pick up the device for overnight use at the Shamrock office located at:
905 W. Eisenhower Circle
Suite 102
Ann Arbor, MI 48103
Monday through Friday 9:00 a.m. to 5:00 p.m.
Toll Free phone: 888-996-4319
I understand that my physician may prescribe an overnight sleep diagnostic test at Sleep Well Centers in Ann Arbor based on the results of the Home Sleep Screen. I agree to use the device on the same night that I receive it. I agree to return the device the NEXT BUSINESS DAY.
Home sleep screening is offered as a complimentary service by Sleep Well Centers. I understand that if I do not return the device the NEXT BUSINESS DAY I will be charged $50 for every additional day I keep it. If there is an emergency preventing the return of the device the NEXT BUSINESS DAY I will immediately call Toll Free: 888-996-4319. Agree

Sleep Well Centers Patient Profile for Sleep Screening

Sleep Well Centers Patient Profile
for Sleep Screening