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Requested Illustration:

1. PLEASE LIST THE DATE OF THE FIRST DIAGNOSIS:

2. PLEASE NOTE TYPE DIAGNOSED:
OBSTRUCTIVE
CENTRAL
MIXED

3. HAS A SLEEP STUDY, OR STUDIES BEEN COMPLETED?
Yes No IF YES, PLEASE NOTE DATE (S) OF STUDY(IES):
FIRST STUDY
LAST STUDY
AND NOTE THE FOLLOWING:
OXYGEN SATURATION LEVEL
APNEA INDEX RESULTS

4. WHAT TREATMENT HAS BEEN PRESCRIBED: (PLEAS CHECK ALL THAT APPLY):
OBSERVATION ALONE
WEIGHT LOSS ALONE
CPAP (CONTINUOUS POSITIVE AIRWAY PRESSURE) MASK IF CHECKED, DATE LAST USED
SURGERY - TRACHEOTOMY OR UVULOPALATOPHARYNGOPLASTY
MEDICATION, IF CHECKED, 
    PLEASE DETAIL TYPE AND DOSAGE:

5. ARE THERE ANY CURRENT SYMPTOMS:
Yes No IF YES, PLEASE DETAIL

6. CLIENT'S OCCUPATION FULL TIME PART TIME

7. HAS THE CLIENT EXPERIENCED ANY OF THE FOLLOWING ILLNESSES: (CHECK ALL THAT APPLY, AND GIVE DETAILS)
ARRHYTHMIA, TYPE

OTHER HEART RELATED CONDITIONS, TYPE

ASTHMA, COPD OR EMPHYSEMA, TYPE

DEPRESSION

OVERWEIGHT, PLEASE CONFIRM HT   WT

8. HAS THE CLIENT SMOKED CIGARETTES IN THE PAST 12 MONTHS:
Yes No IF YES, PLEASE DETAIL AMOUNT PER DAY AND DATE STOPPED, IF NO LONGER SMOKING:

9. HAS A PARENT, BROTHER OR SISTER DIED PRIOR TO AGE 65, OTHER THAN BY ACCIDENT? Yes No IF YES, PLEASE DETAIL

10. DOES THE CLIENT EXERCISE THREE OR MORE TIMES PER WEEK?
Yes No IF YES, PLEASE DETAIL

11. PLEASE LIST ANY OTHER ILLNESSES OR IMPAIRMENTS, ALONG WITH ANY AND ALL MEDICATIONS CURRENTLY BEING TAKEN, INCLUDE THE DOSAGE AND FREQUENCY OF EACH: