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CME / CNE Informed Consent Form
Font :  S M L LL

Often
Seldom
Never
 
Restless sleep
Very loud, heavy snoring
Decreased daytime alertness
Sleepiness during the day after sleeping throughout the night
Awakening suddenly during the night, gasping for breath
Overweight
Easily irritated with a short temper
Tendency to be very forgetful
Mood or behavior changes
Morning headaches
Decreased interest in sex
Anxiety or depression

If you've checked "often" in more than two boxes, you may be experiencing symptoms of sleep apnea. Consult your physician or a specialist, or call the Sleep & Respiratory Disorder Center at the Hong Kong Adventist Hospital for addition information. Simply fill out the personal information record, and turn it in at the outpatient registration desk, mail or fax it.

Personal Information Record
Name:
Mailing Address:
Contact Telephone:
Fax Number:

Yes, I would like more information about the Sleep & Respiratory Center at the Hong Kong Adventist Hospital
Yes, I would like to make an appointment for an evaluation

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