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. The home sleep screening unit will be shipped to my home by Sleep Well Centers. Based on the results of this home sleep screening my physician may prescribe an in lab sleep diagnostic test. I agree to use the device on the same night that I receive the unit from Sleep Well Centers. Further, I agree to return the device the NEXT DAY in the prepaid UPS shipping package. The screening service will be free of charge if you follow these directions. I understand that I will be charged $50/day if I don’t return the unit in the prepaid UPS shipping package the NEXT DAY. If there is an emergency preventing you from returning the device NEXT DAY please call 888-996-4319 and we will waive the late fee and work with you to return the device the following day. Agree

Sleep Well Centers Patient Profile for Sleep Screening

Sleep Well Centers Patient Profile
for Sleep Screening