Panthera Initial Screening | Snoreeze Snoring Relief

1. Patient Information

Please indicate if any of the following applies to you, giving further details if necessary:

Your Name *

Your Email Address *

Your Phone Number (optional)

Your Height

Your Weight

2. Your Sleep Problem

Please indicate if any of the following applies to you, giving further details if required:

I snore most nights

Yes
No

Details 1

My snoring disturbs others

Yes
No

Details 2

I sometimes have headaches when I wake up

Yes
No

Details 3

I need to go to the bathroom frequently during the night

Yes
No

Details 4

I have a previous diagnosis of OSA or other sleep disorder.

Yes
No

Details 5

I have previously tried treatments for snoring or OSA e.g. CPAP, lifestyle change, etc

Yes
No

Details 6

3. OSA Risk Assesment

Please answer each question below and record the total number of YES answers in the space provided. The score will give an indication of OSA risk.

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Total Number of YES Answers

4. Assessment of Daytime Sleepiness

Please indicate how likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired. This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation.

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5. Relevant Medical History

Please indicate whether you have suffered with any of these conditions personally or have any family history. Please provide further details when the answer is yes and if any personal conditions are well controlled.

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6. Medications, Alcohol and Smoking

Do you take any prescribed medicines?

Alcohol consumption (average units per week)

Smoking (average weekly amount)

Initial Screening Assessment

1. Patient Information

2. Your Sleep Problem

3. OSA Risk Assesment

4. Assessment of Daytime Sleepiness

5. Relevant Medical History

6. Medications, Alcohol and Smoking