Name: CanSleep Services Inc
Price range: $

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1.844.SLEEP40

Our family of clinics to support you include:

Patient Symptoms

Patient information
Name*
First Last
Date of Birth (dd/mm/yyyy)*
DD slash MM slash YYYY
Age
Height (cm)
Weight (kg)
Gender
On disability/government assistance?
- Yes
- No
Email*
I agree to receive email correspondence such as appointment reminders, promotions, and information regarding treatment
- I agree
- I do not agree
Phone*
Referring Doctor*
Extended Health Provider*
Policy or Plan Number and Member ID or ID Number*
Secondary Coverage – Extended Health
Policy holder name
Policy holder date of birth (dd/mm/yyyy)
DD slash MM slash YYYY
Policy or Plan Number and Member ID or ID Number

The policy or plan number and member ID or ID number for your secondary coverage.
Health information
Symptoms*
Please carefully read and check the boxes that are applicable. This is an important part of your screening.
- Snoring
- Stopping Breathing
- Gasping, choking or snorting during sleep
- Sleepiness/nodding off while driving
- Frequent awakenings
- Restless Sleep
- Limbs jerking or twitching at night
- Morning headache
- Insomnia
- Restless legs
- Memory loss/poor concentration
- Teeth clenching/teeth grinding
- Night sweats
- Frequent nighttime bathroom trips
- Family history of sleep apnea
- Waking unrefreshed
Previous sleep diagnosis & treatment
- Overnight Oximetry/Level III Testing
- Overnight In Sleep Lab/Hospital
- CPAP/BIPAP Therapy
- Oral Appliance Therapy
Health Issues
- Heart disease
- Pacemaker
- Gastric/Acid reflux
- Emphysema/COPD
- Depression
- Claustrophobia
- Chronic pain
- Chronic sinus congestion
- Increased blood pressure
- Fibromyalgia
- Recent head injury
- Other lung disease
- Oxygen therapy
- Shift work
- Stroke
- Pneumothorax
- Seizure
- Weight gain
- Diabetes
- Sensitive skin
Other health issues
Allergies
Medications (names only, dose not required)
Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following scenarios?

This refers to normal daytime activity over the past several weeks or months.

	No chance of dozing	Slight chance of dozing	Moderate chance of dozing	High chance of dozing
Sitting & reading
Watching TV
Sitting inactive in a public place
As a passenger in a car for an hour
Laying down in the afternoon
Sitting & talking to someone
Sitting quietly after lunch (no alcohol)
In a car & stopped for a few minutes

Release of Information
Release of Information for insurance*
I authorize CanSleep Services to send an estimate, sleep study results and any other medical documentation required for pre-approval purposes. I understand that this is for information purposes and there is nothing being claimed with my insurance provider at this time. By supplying my home/cell phone number, email address and any other personal information, I authorize CanSleep Services to use my personal information to contact me regarding appointment times, referral notices, result information, appointment reminders, and other limited information. I am also aware it is my responsibility to keep my contact information current.
- I agree
Phone
This field is for validation purposes and should be left unchanged.

Patient Symptoms

Patient information

Health information

Epworth Sleepiness Scale

Release of Information