Questionnaire - Level 1 Diagnostics

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Pre-evaluation Questionnaire
* Level 1 Diagnostics follows HIPPA confidentiality laws and would never share any patient information. Your questionnaire will be sent directly to
Level 1 Diagnostics.
Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Phone*
Email*
Company*
Height ____ft. ____in.*
Weight*
Age*
Birthdate*
MM slash DD slash YYYY
Cardiovascular
Please fill out to the best of your ability and be sure and click the submit button when you are finished.
Do you smoke or have you smoked?*
- Yes
- No
Has anyone in your immediate family (father, mother, sister, brother, grandparent(s), aunts or uncles (blood relatives) been diagnosed with cardiovascular disease?*
- Yes
- No
Do you have diabetes?*
- Yes
- No
Do you have elevated cholesterol or triglycerides?*
- Yes
- No
Do you stand up and get light headed?*
- Yes
- No
Do you have hypertension, high blood pressure, or take blood pressure medicine?*
- Yes
- No
Do you have varicose veins?*
- Yes
- No
Do you have erectile dysfunction? (Men)
- Yes
- No
Do you have heart palpitations or heart “flutters“?*
- Yes
- No
Have you ever had a sudden loss of vision in one eye, usually lasting only seconds?*
- Yes
- No
Have you been diagnosed with any type of heart ailment, heart disease, or cardiovascular disease?*
- Yes
- No
If so, what?
Do you have or easily get cold hands or feet?*
- Yes
- No
Do you have gum disease, gingivitis, or periodontitis?*
- Yes
- No
When walking or exercising, do you get leg pain or cramping?*
- Yes
- No
Sleep

Epworth
Sitting and Reading*
- Would never doze
- Slight chance of dozing
- Moderate chance of dozing
- High chance of dozing
Watching Television*
- Would never doze
- Slight chance of dozing
- Moderate chance of dozing
- High chance of dozing
Sitting inactive in a public place, for example, a theater or a meeting*
- Would never doze
- Slight chance of dozing
- Moderate chance of dozing
- High chance of dozing
As a passenger in a car for an hour without a break*
- Would never doze
- Slight chance of dozing
- Moderate chance of dozing
- High chance of dozing
Lying down to rest in the afternoon*
- Would never doze
- Slight chance of dozing
- Moderate chance of dozing
- High chance of dozing
Sitting quietly after lunch when you’ve had no alcohol*
- Would never doze
- Slight chance of dozing
- Moderate chance of dozing
- High chance of dozing
In a car while stopped in traffic*
- Would never doze
- Slight chance of dozing
- Moderate chance of dozing
- High chance of dozing
Have you ever had a sleep study done?*
- Yes
- No
Do you use or have you tried a CPAP?*
- Yes
- No
Stop Bang
Snoring?
Do you snore Loudly (loud enough to be heard through closed doors or your partner has to wear ear plugs or elbow you at night)?*
- Yes
- No
Tired?
Do you often feel tired, fatigued, or sleepy during the daytime?*
- Yes
- No
Observed?
Has anyone observed you stop breathing during your sleep?*
- Yes
- No
Pressure?
Do you have or are being treated for high blood pressure?*
- Yes
- No
Body Mass Index more than 35 kg/m2?*
- Yes
- No
See BMI Caculator
Do you Weigh More for your height than is shown in the table below:*
- Yes
- No
Click on chart to view larger
Age?
Are you older than 50 years old?*
- Yes
- No
Neck size large?
For male, is your shirt collar 17 inches or larger? For female, is your shirt collar 16 inches or larger?
- Yes
- No
GENDER = Male?*
- Yes
- No
Pulmonary
Do you have asthma?*
- Yes
- No
Do you have COPD?*
- Yes
- No
Do you have difficulty breathing?*
- Yes
- No
Do you have a history of pneumonia?*
- Yes
- No
Do you take the medication Amiodarone?*
- Yes
- No
Captcha

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Pre-evaluation Questionnaire

Cardiovascular

Sleep

Epworth

Stop Bang

Pulmonary