MEDICAL FORM

    1. PATIENT INFORMATION

    2. HOW LIKELY ARE YOU TO DOZE OFF OR FALL ASLEEP IN THE FOLLOWING SITUATIONS?

    2.1) Sitting & Reading

    0123

    2.2) Watching TV
    0123
    2.3) Sitting, inactive in a public place (e.g. a theater or a meeting)

    0123
    2.4) As a passenger in a car for an hour without a break
    0123
    2.5) Lying down to rest in the afternoon when circumstances permit

    0123
    2.6) Sitting and talking to someone
    0123
    2.7) Sitting quietly after lunch without alcohol

    0123
    2.8) In a car, while stopped for a few minutes in traffic
    0123

    3. OBSERVATIONS

    Apena:

    YesNoSometimes
    Awakenings:
    <1 /Night2 to 3 /Night>3 /Night
    Morning Headaches:

    YesNo
    Snoring:
    LightModerateStrong
    Condition on Wake up:

    BadNormalVery Good
    Other Observations:

    4. CONCLUSION

    Required Tests:
    Polygraph(PG)Polysomnography(PSG)Other

    We offer a One-Stop-Shop approach that encompasses screening, diagnosis, treatment and ongoing care

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    Office 503, 5TH FLOOR AL NABOODHA BLOCK A, AL SHOALA BUILDING DEIRA, Al Etihad Rd. PO BOX 31303 Dubai - UAE

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