WESTERN TEAMSTERS WELFARE TRUST SLEEP SCREENING *required fields Step 1 of 5 - Contact Information 20% First Name*Last Name*Email* Phone* Personal Info*MaleFemaleDate of Birth*Neck SizeHeightWeightBMI Check any that you experience and list any meds you currently take for each.High Blood Pressure Blood Pressure MedicationsHypothyroidism Hypothyroidism MedicationsCholesterol Cholesterol MedicationsDiabetes Diabetes MedicationsHeart Condition Heart MedicationsAsthma/COPD Asthma/COPD MedicationsAllergies Allergy MedicationsIndigestion Indigestion MedicationsStroke, Heart Attack, CAD or DM Describe, When/Where How likely are you to doze off or fall asleep in the following situationsSitting and ReadingUnlikelyMaybeProbablyDefinitelyWatching TelevisionUnlikelyMaybeProbablyDefinitelySitting Quietly in a Public PlaceUnlikelyMaybeProbablyDefinitelyRiding in a CarUnlikelyMaybeProbablyDefinitelyDriving a CarUnlikelyMaybeProbablyDefinitelyLying Down in the AfternoonUnlikelyMaybeProbablyDefinitelySitting and TalkingUnlikelyMaybeProbablyDefinitelySitting Quietly After LunchUnlikelyMaybeProbablyDefinitelyIn a Stopped CarUnlikelyMaybeProbablyDefinitely Check any that you experience and comment as necessary.Nose Breathing Problem DescribeTrouble Sleeping DescribeSnoring DescribeSleep Apnea DescribePrevious Sleep Study WhenAuto Accident From Sleeping DescribeNameThis field is for validation purposes and should be left unchanged.
