Sleep Apnea

Sleep Apnea Questionnaire
Please answer all questions applicable to the client's medical history.
Questions? Call Jim or Teresa at 877.564.1707.
Producer Name*
Phone*
Email*
Date
MM slash DD slash YYYY
Client Name
Date of Birth
MM slash DD slash YYYY
Gender
- Male
- Female
Face Amount
Max Premium $/year
Type
Has the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)?
- Yes
- No
Frequency
Date of Last Use
Type
Date of diagnosis:
MM slash DD slash YYYY
Diagnosed as:
- Obstructive
- Central
- Mixed
- Unknown
Severity:
- Severe
- Moderate
- Mild
Has an overight sleep study been done?
- Yes
- No
If Yes, provide sleep index AHI and RDI:
Lowest oxygen saturation (%):
How is the sleep apnea being treated?
- No treatment
- Medicated
- Weight loss
- CPAP Mask
- Surgery (UPPP)
- Surgery (tracheotomy)
- Other
If Other, please specify.
Does the client have any of the following:
- Overweight
- Arrhythmia
- Coronary Artery Disease
- Stroke
- Depression
- Lung Disease
If yes to any above, please provide details:
Does the client use alcohol?
- Yes
- No
If yes, describe usage:

Medications

Click the + sign to add additional medications.

Name of Medication (prescription or otherwise)	Dates Used	Quantity Taken	Frequency Taken

List any other major health problems the client has:
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