Dr. Halstrom | Screening - Dr. Halstrom

604-876-8993

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Treating Sleep Apnea and Snoring Since 1994
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Obstructive sleep apnea during REM sleep & blood pressure.

Obstructive sleep apnea during REM sleep: effects on morning and evening blood pressure. This new...

March 11th, 2023

Fantastic New Device – SomnoDent Avant

Dr. Halstrom is happy to report that our recent results using the SomnoMed Avant device are simply...

January 13th, 2023

Screening

Please complete the following sleep apnea screening.

We will be in touch to discuss the results and answer further questions.

Sleep Apnea Screening Form

Name*
First Last
How did you first find out about us?*
Email*
Phone
City
Age Range*
- 18 - 30
- 30 - 40
- 40 - 50
- 50 - 60
- 60 - 70
- 70+
Weight (Pounds)*
Neck Size (Inches)*
Gender
Do you have Extended Health Insurance
- Yes
- No
Extended Health Insurance Provider
Have you had previous sleep testing?
- No
- Yes: At Home
- Yes: In Sleep Lab
Sleep Apnea Testing Diagnosis (If Applicable)
- Mild
- Moderate
- Severe
EPWORTH - Sleep Questionnaire^*

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. Select the most appropriate answer for each situation.
Sitting Reading*
- 0 - No Chance of Dozing
- 1 - Slight Chance of Dozing
- 2 - Moderate Chance of Dozing
- 3 - High Chance of Dozing
Watching TV*
- 0 - No Chance of Dozing
- 1 - Slight Chance of Dozing
- 2 - Moderate Chance of Dozing
- 3 - High Chance of Dozing
Sitting inactive in a public place (theatre or a meeting)*
- 0 - No Chance of Dozing
- 1 - Slight Chance of Dozing
- 2 - Moderate Chance of Dozing
- 3 - High Chance of Dozing
As a passenger in a car for an hour without a break.*
- 0 - No Chance of Dozing
- 1 - Slight Chance of Dozing
- 2 - Moderate Chance of Dozing
- 3 - High Chance of Dozing
Lying down to rest in the afternoon when circumstances permit.*
- 0 - No Chance of Dozing
- 1 - Slight Chance of Dozing
- 2 - Moderate Chance of Dozing
- 3 - High Chance of Dozing
Sitting talking to someone.*
- 0 - No Chance of Dozing
- 1 - Slight Chance of Dozing
- 2 - Moderate Chance of Dozing
- 3 - High Chance of Dozing
Sitting Quietly after a lunch without alcohol.*
- 0 - No Chance of Dozing
- 1 - Slight Chance of Dozing
- 2 - Moderate Chance of Dozing
- 3 - High Chance of Dozing
In a car, while stopped for a few minutes in traffic.*
- 0 - No Chance of Dozing
- 1 - Slight Chance of Dozing
- 2 - Moderate Chance of Dozing
- 3 - High Chance of Dozing
MAP - Sleep Questionnaire:^*

Rate Yourself On The Following Questions.
Loud Snoring?*
- Never
- Rarely (less than once per week)
- Sometimes (1-2 times per week)
- Frequently (3-4 times per week)
- Always (5-7 times per week)
- Do Not Know
Your legs feel jumpy or jerk?*
- Never
- Rarely (less than once per week)
- Sometimes (1-2 times per week)
- Frequently (3-4 times per week)
- Always (5-7 times per week)
- Do Not Know
Difficulty falling asleep?*
- Never
- Rarely (less than once per week)
- Sometimes (1-2 times per week)
- Frequently (3-4 times per week)
- Always (5-7 times per week)
- Do Not Know
Frequent awakenings?*
- Never
- Rarely (less than once per week)
- Sometimes (1-2 times per week)
- Frequently (3-4 times per week)
- Always (5-7 times per week)
- Do Not Know
Snorting or gasping?*
- Never
- Rarely (less than once per week)
- Sometimes (1-2 times per week)
- Frequently (3-4 times per week)
- Always (5-7 times per week)
- Do Not Know
Falling asleep when at work?*
- Never
- Rarely (less than once per week)
- Sometimes (1-2 times per week)
- Frequently (3-4 times per week)
- Always (5-7 times per week)
- Do Not Know
Frequent tossing, turning or thrashing?*
- Never
- Rarely (less than once per week)
- Sometimes (1-2 times per week)
- Frequently (3-4 times per week)
- Always (5-7 times per week)
- Do Not Know
Your breathing stops or you choke or struggle from breath?*
- Never
- Rarely (less than once per week)
- Sometimes (1-2 times per week)
- Frequently (3-4 times per week)
- Always (5-7 times per week)
- Do Not Know
Excessive sleepiness?*
- Never
- Rarely (less than once per week)
- Sometimes (1-2 times per week)
- Frequently (3-4 times per week)
- Always (5-7 times per week)
- Do Not Know
Morning Headaches*
- Never
- Rarely (less than once per week)
- Sometimes (1-2 times per week)
- Frequently (3-4 times per week)
- Always (5-7 times per week)
- Do Not Know
Feeling paralyzed, unable to move for short periods when falling asleep or awakening?*
- Never
- Rarely (less than once per week)
- Sometimes (1-2 times per week)
- Frequently (3-4 times per week)
- Always (5-7 times per week)
- Do Not Know
Find yourself in a vivid dreamlike state when falling asleep or awakening even though you know you are awake?*
- Never
- Rarely (less than once per week)
- Sometimes (1-2 times per week)
- Frequently (3-4 times per week)
- Always (5-7 times per week)
- Do Not Know
Any snoring?*
- Never
- Rarely (less than once per week)
- Sometimes (1-2 times per week)
- Frequently (3-4 times per week)
- Always (5-7 times per week)
- Do Not Know
Additional symptoms during sleep suggesting "Sleep Apnea" - check all applicable:
- Broken Sleep
- Acid Reflux
- Irregular Heartbeat
- Night Sweats
- Trouble Controlling Weight
- Excess Urination - Frequent Trips To Bathroom
- Clench or Grind Teeth At Night
Additional conditions suggesting or associated with "High Risk for Sleep Apnea" - check all applicable:
- Stroke / Mini-Stroke / TIA
- Narcotic Treatment
- Erectile Dysfunction
- Congestive Heart Failure
- Diabetes / Kidney Disease
- Chronic Depression
- Heart Attack / Angina
- Low Thyroid
- High Blood Pressure

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About Dr. Halstrom

With a great deal of good fortune I was able to walk away from a serious single car accident. Following the accident I was diagnosed with sleep apnea. I tried CPAP therapy unsuccessfully, as I was unable to accommodate to the daily requirements of wearing the mask....Read More

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