O2 Screening and Polysomnogram

O2 Screening & Sleep Study

Info:

Name:

Surname:

Doctor:

Date of Birth:

Email address:

Height:

Weight:

Neck circumference:

Gender:

History:

MEDICATION:

COMMENTS:

Daytime - Symptoms experienced during normal daily routine.

Nighttime - Symptoms experienced during sleep.

Signature of Patient:

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[field id="Name"]

[field id="Surname"]

[field id="Male/Female"]

[field id="Date of Birth"]

[field id="Doctor"]

[field id="Neckcircumference:"]

[field id="Dateofdiagnosed"]

[field id="EmailAddress:"]

[field id="Ex-Covid 19"]

[field id="Height"]

[field id="Weight"]

[field id="Asthmatic"]

[field id="Smoking"]

[field id="Hypertension"]

[field id="Allergy"]

[field id="Sinusitis"]

[field id="HST of broken nose"]

[field id="Depression"]

[field id="Diabetes"]

[field id="HeartProblems"]

[field id="lungProblems"]

[field id="MEDICATION"]

[field id="COMMENTS"]

[field id="morning"]

[field id="Dry"]

[field id="Depression"]

[field id="concentration"]

[field id="fatigue"]

[field id="Sleepiness"]

[field id="Weightq"]

[field id="snoring"]

[field id="Choking"]

[field id="Episodes"]

[field id="Restless"]

[field id="bathroom"]

[field id="Insomnia"]

[field id="Nightmares"]