Blooms CPAP ClinicOnline Sleep Apnoea Test Part 1 of 2: Epworth Sleepiness ScaleHow likely are you to doze off or fall asleep during the following situations, in contrast to just feeling tired? Even if you have not done some of these things recently, try to work out how they would have affected you.Q1: Sitting and reading*Would never dozeSlight chance of dozingModerate chance of dozingHigh chance of dozingQ2: Watching television*Would never dozeSlight chance of dozingModerate chance of dozingHigh chance of dozingQ3: Sitting inactive in a public place (e.g. a theatre/meeting)*Would never dozeSlight chance of dozingModerate chance of dozingHigh chance of dozingQ4: As a passenger in a car for an hour with no break*Would never dozeSlight chance of dozingModerate chance of dozingHigh chance of dozingQ5: Lying down in the afternoon (when possible)*Would never dozeSlight chance of dozingModerate chance of dozingHigh chance of dozingQ6: Sitting and talking to someone*Would never dozeSlight chance of dozingModerate chance of dozingHigh chance of dozingQ7: Sitting quietly after lunch without alcohol*Would never dozeSlight chance of dozingModerate chance of dozingHigh chance of dozingQ8: In a car, while stopped for a few minutes in traffic*Would never dozeSlight chance of dozingModerate chance of dozingHigh chance of dozing Part 2 of 2: OSA QuestionnaireThe following questions were pioneered by the University Health Network and follow the STOP-BANG format. On average, how many hours of sleep do you get?*Less than 3 Hours3 - 6 Hours6 - 8 HoursOver 8 HoursDo you often snore loudly?*loud enough to be heard through closed doorsYesNoDo you often feel Tired, Fatigued, or Sleepy during the daytime?*e.g. falling asleep while driving or talking to someoneYesNoHas anyone Observed you Stop Breathing or Choking/Gasping during your sleep?*YesNoDo you have or are being treated for High Blood Pressure?*YesNoIs your neck size large? (Measured around Adams apple)*For male, is your shirt collar 17 inches/ 43cm or larger?For female, is your shirt collar 16 inches / 41cm or larger?YesNoWhat is your gender?*On average, Males are more likely to have sleep apnoea.MaleFemaleAre you older than 50?*YesNoBMI CalculationHeight (cm)*Please Select High...120 cm121 cm122 cm123 cm124 cm125 cm126 cm127 cm128 cm129 cm130 cm131 cm132 cm133 cm134 cm135 cm136 cm137 cm138 cm139 cm140 cm141 cm142 cm143 cm144 cm145 cm146 cm147 cm148 cm149 cm150 cm151 cm152 cm153 cm154 cm155 cm156 cm157 cm158 cm159 cm160 cm161 cm162 cm163 cm164 cm165 cm166 cm167 cm168 cm169 cm170 cm171 cm172 cm173 cm174 cm175 cm176 cm177 cm178 cm179 cm180 cm181 cm182 cm183 cm184 cm185 cm186 cm187 cm188 cm189 cm190 cm191 cm192 cm193 cm194 cm195 cm196 cm197 cm198 cm199 cm200 cm201 cm202 cm203 cm204 cm205 cm206 cm207 cm208 cm209 cm210 cm211 cm212 cm213 cm214 cm215 cm216 cm217 cm218 cm219 cm220 cmWeight (Kg)*Please Select Weight...25 Kg26 Kg27 Kg28 Kg29 Kg30 Kg31 Kg32 Kg33 Kg34 Kg35 Kg36 Kg37 Kg38 Kg39 Kg40 Kg41 Kg42 Kg43 Kg44 Kg45 Kg46 Kg47 Kg48 Kg49 Kg50 Kg51 Kg52 Kg53 Kg54 Kg55 Kg56 Kg57 Kg58 Kg59 Kg60 Kg61 Kg62 Kg63 Kg64 Kg65 Kg66 Kg67 Kg68 Kg69 Kg70 Kg71 Kg72 Kg73 Kg74 Kg75 Kg76 Kg77 Kg78 Kg79 Kg80 Kg81 Kg82 Kg83 Kg84 Kg85 Kg86 Kg87 Kg88 Kg89 Kg90 Kg91 Kg92 Kg93 Kg94 Kg95 Kg96 Kg97 Kg98 Kg99 Kg100 Kg101 Kg102 Kg103 Kg104 Kg105 Kg106 Kg107 Kg108 Kg109 Kg110 Kg111 Kg112 Kg113 Kg114 Kg115 Kg116 Kg117 Kg118 Kg119 Kg120 Kg121 Kg122 Kg123 Kg124 Kg125 Kg126 Kg127 Kg128 Kg129 Kg130 Kg131 Kg132 Kg133 Kg134 Kg135 Kg136 Kg137 Kg138 Kg139 Kg140 Kg141 Kg142 Kg143 Kg144 Kg145 Kg146 Kg147 Kg148 Kg149 Kg150 Kg151 Kg152 Kg153 Kg154 Kg155 Kg156 Kg157 Kg158 Kg159 Kg160 Kg161 Kg162 Kg163 Kg164 Kg165 Kg166 Kg167 Kg168 Kg169 Kg170 Kg171 Kg172 Kg173 Kg174 Kg175 Kg176 Kg177 Kg178 Kg179 Kg180 Kg181 Kg182 Kg183 Kg184 Kg185 Kg186 Kg187 Kg188 Kg189 Kg190 Kg191 Kg192 Kg193 Kg194 Kg195 Kg196 Kg197 Kg198 Kg199 Kg200 KgBMI*Height divisionPatient ResultsFirst Name*Last Name*Email*You will receive an email with your test results. Enter Email Confirm Email Phone (optional)Sleep Test Reference CodeEpworth ResultEpworth Calculated ResultEpworth Risk FactorSTOP ResultBANG ResultSTOPBANG ResultSTOPBANG Risk FactorBlooms Online Sleep Test Result This iframe contains the logic required to handle Ajax powered Gravity Forms.