Personal Information





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MaleFemale












Calculation based on height and weight applied to the conventional BMI equation.








Medical History

Do you have or have you ever been diagnosed or treated for any of the following conditions?

High Blood PressureHeart DiseaseLung DiseaseDepressionDiabetesStrokeSleep ApneaRestless Leg Syndrome or PLMSOther

Sleep History

Do you have or have you ever been diagnosed or treated for any of the following conditions?

YesNo
Do you snore?

YesNo
If yes, is it loud enough to be heard through walls or a door?

YesNo
Has anyone ever told you that you stop breathing when you are sleeping?

YesNo
Do you ever wake gasping for breath?

YesNo
Do you ever wake with your heart racing?

YesNo
Do you still feel tired after a full night’s sleep?

YesNo
Do you ever feel tired/sleepy during the day?

YesNo
Do you fall asleep at inappropriate times? (during a movie, driving)

YesNo
Do you currently use a CPAP machine? If yes, what pressure?

When were you first diagnosed with OSA?

How long has it been since your last follow-up visit with your physician regarding your OSA treatment?

When was the last time your equipment was checked and the numbers were recorded?

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Dr. John’s Medical Solutions

Please contact us for more information or to sign up for your overnight sleep test and treatment.


Mailing Address
Address: PO Box 945,
Brentwood, TN 37024

Phone: 800-257-9214
Email: info@docjmd.com


Call Center

Phone: 615-855-1356