Beluga Portal

Simon Svenman

Male · 9/25/1988 (36y) · NC menuDots

Phone: 9198976992

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Master Id: 003TN00000O3BPLYA3-003TN00000O3BPLYA3-1

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Created on: 3-26-2025

Updated on: 3-26-2025

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Master Id: 003TN00000O3BPLYA3-003TN00000O3BPLYA3-1

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First Name	Simon
Last Name	Svenman
Date of Birth	09/25/1988
Phone Number	9198976992
Email	simon.svenman@gmail.com
Address	700 Corporate Center Drive Apt. 461
City	Raleigh
State	NC
Zip	27607
Sex	Male
Self-reported Meds	N/A
Allergies	N/A
Medical Conditions	N/A
Do you snore loudly? a) Very seldom b) Yes, and it bothers me or my partner c) Yes, it wakes me up sometimes d) Often. I wake up multiple times a night	Often. I wake up multiple times a night
Do you ever stop breathing, gasp, or choke while sleeping? a) Yes b) No c) I'm not sure	Yes
Have you ever been diagnosed with Sleep Apnea? a) No b) Yes	Yes
Select any of the following options that apply to you: a) Ischemic Heart Disease b) Hypertension/high blood pressure c) Insomnia d) Mood disorder e) None of the above f) History of stroke	None of the above
Your chances of dozing off while sitting & reading: a) No chance of dozing b) Slight chance of dozing c) Moderate chance of dozing d) High chance of dozing	Moderate chance of dozing
Your chances of dozing off while watching TV: a) No chance of dozing b) Slight chance of dozing c) Moderate chance of dozing d) High chance of dozing	Moderate chance of dozing
Your chances of dozing off while sitting inactive in a public place (e.g. a theater or meeting): a) No chance of dozing b) Slight chance of dozing c) Moderate chance of dozing d) High chance of dozing	Slight chance of dozing
Your chances of dozing off while as a passenger in a car for an hour without a break: a) No chance of dozing b) Slight chance of dozing c) Moderate chance of dozing d) High chance of dozing	High chance of dozing
Your chances of dozing off while lying down to rest in the afternoon when circumstances permit: a) No chance of dozing b) Slight chance of dozing c) Moderate chance of dozing d) High chance of dozing	High chance of dozing
Your chances of dozing off while sitting and talking to someone: a) No chance of dozing b) Slight chance of dozing c) Moderate chance of dozing d) High chance of dozing	Slight chance of dozing
Your chances of dozing off while sitting quietly after a lunch without alcohol: a) No chance of dozing b) Slight chance of dozing c) Moderate chance of dozing d) High chance of dozing	High chance of dozing
Your chances of dozing off while in a car, while stopped for a few minutes in traffic: a) No chance of dozing b) Slight chance of dozing c) Moderate chance of dozing d) High chance of dozing	Slight chance of dozing
Do you currently or have you ever used CPAP? a) No, I have not used CPAP b) Yes, I have used CPAP	No, I have not used CPAP
Please select any options that apply for the following statement: I have not attempted to use a CPAP device to manage my sleep-related breathing disorder and am refusing to attempt for the following reason(s): a) Latex allergy b) Claustrophobia c) The mask/device/headgear will cause me discomfort or restrict my movement during sleep d) The noise from the device will disturb me and/or my bed partner’s sleep e) None – I am willing to try CPAP f) Other (please describe) g) Concern of pressure on upper lip causing tooth-related problems	Claustrophobia The mask/device/headgear will cause me discomfort or restrict my movement during sleep The noise from the device will disturb me and/or my bed partner’s sleep
Are you able to breathe through your nose? a) No b) Yes	Yes
Do you have any dental work that is loose or wobbly? a) No b) Yes	No
Are you allergic to vinyl polysiloxane (silicone)? a) No b) Yes	No
Do you have any questions for your physician about Sleep Apnea testing and treatment? (free text)	N/A