Sleep Disorders Services for Providers, Partners, and Patients

Sleep History Questionnaire

Complete and Submit the Form Below

A member of our team will contact you shortly.

Patient Information






    STOP-BANG Sleep Apnea Questionnaire

    STOP

    Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors)?

    YesNo

    Do you often feel TIRED, fatigued, or sleepy during daytime?

    YesNo

    Has anyone OBSERVED you stop breathing or choking/gasping during your sleep?

    YesNo

    Do you have or are you being treated for high blood PRESSURE?

    NoYes

    BANG

    BMI Calculation inputs:

    Height: Ft In

    Weight (lbs):

    AGE over 50 years old?

    YesNo

    NECK Circumference:

    Neck size (inches):

    GENDER: Male?

    YesNo


    NightWatch Sleep
    Please contact us for more information or to sign up for your overnight sleep test and treatment.

    Mailing Address
    Address: PO Box 945
    Brentwood, TN 37024

    Email: info@nightwatchsleep.com
    Fax: 615-794-9792