If your client has sleep apnea, please answer the following :


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   


   1.  Date of first diagnosis ? 


   2.  Was the sleep apnea diagnosed as ?
       Obstructive
       Central
       Mixed
       Unknown


   3.  How is the sleep apnea being treated?
       Observation Alone
       CPAP Mask
       Weight Loss
       Surgery
       Other, give details 


   4.  Is your client on any medication ? Yes   No 

       If yes, give details: 


   5.  Check if your client has had problems with any of the following :
        Lung Disease
        Chest Pain or Coronary Artery Disease
        Depression
        Overweight
        Arrhythmia
        Stroke



   6.  Has your client smoked cigarettes in the last 12 months ? Yes   No 


   7.  Does your client have any major health problems ? Yes   No 

       (example: cancer, etc.)

       If yes, give details: