Patient Questionnaire

This questionnaire is for patients that have already been scheduled at one of our facilities for an appointment. It will take approximately 10 to 15 minutes to complete. Please contact our scheduling office if you have any questions or would like to make an appointment; 877-SLEEPHC or 877-753-3742.

This questionnaire has been compiled on the basis of many years of accumulated experience in Sleep Medicine. Please respond to all questions. The information you provide is VERY important and will assist the sleep specialist during the review of your sleep data. This information will be treated with the utmost discretion and will not be used by any party other than Sleep HealthCenters.

To Download and Print (please use BLACK ink to complete this form)

Please choose appropriate questionnaire from link below. After completing the questionnaire, please fax toll-free to 866-799-0601.

• Adult Sleep Questionnaire
• Pediatric Sleep Questionnaire

To Complete Online

Please make selection from link below. Important: Please do not use your browser's BACK button while completing the online questionnaire as you may lose information you have entered.

• Adult Sleep Questionnaire
• Pediatric Sleep Questionnaire

Sleep HealthCenters uses SSL (Secure Sockets Layer), the industry standard security protocol, to process this questionnaire. When communicating with a secure server like our own, your browser will encrypt the information you send. This questionnaire will be transmitted directly to Sleep HealthCenters staff. To review our Notice of Privacy Practices describing how we may use and disclose your medical information, including this questionnaire, click here.