Your name:
*
Email address:
(for emailing your results)
*
Phone number:
Address:
Your zip code:
*
Your weight:
lbs
*
Height:
4'
5'
6'
7'
0"
1"
2"
3"
4"
5"
6"
7"
8"
9"
10"
11"
12"
*
Please answer these questions to help us gauge your risk of Sleep Apnea:
Sitting and reading
NEVER doze in this situation
SLIGHT chance of dozing in this situation
MODERATE chance of dozing in this situation
HIGH chance of dozing in this situation
*
Watching television
NEVER doze in this situation
SLIGHT chance of dozing in this situation
MODERATE chance of dozing in this situation
HIGH chance of dozing in this situation
*
Sitting inactive in a public place
such as a theater or meeting
NEVER doze in this situation
SLIGHT chance of dozing in this situation
MODERATE chance of dozing in this situation
HIGH chance of dozing in this situation
*
As a passenger in a car for an hour
without a break
NEVER doze in this situation
SLIGHT chance of dozing in this situation
MODERATE chance of dozing in this situation
HIGH chance of dozing in this situation
*
Lying down to rest in the afternoon.
NEVER doze in this situation
SLIGHT chance of dozing in this situation
MODERATE chance of dozing in this situation
HIGH chance of dozing in this situation
*
Sitting and talking
NEVER doze in this situation
SLIGHT chance of dozing in this situation
MODERATE chance of dozing in this situation
HIGH chance of dozing in this situation
*
Sitting quietly after lunch (without
alcohol)
NEVER doze in this situation
SLIGHT chance of dozing in this situation
MODERATE chance of dozing in this situation
HIGH chance of dozing in this situation
*
In a car while stopped in traffic
NEVER doze in this situation
SLIGHT chance of dozing in this situation
MODERATE chance of dozing in this situation
HIGH chance of dozing in this situation
*
Do you snore?
Yes
No
Don't Know
*
If yes, your snoring is:
Slightly louder than breathing
As loud as talking
Louder than talking
Very loud - can be heard in adjacent rooms
*
How often do you snore?
Nearly every day
3-4 times a week
1-2 times a week
Never or nearly never
*
Has your snoring ever bothered other
people?
Yes
No
Don't know
*
Has anyone noticed that you quit
breathing during your sleep?
Nearly every day
3-4 times a week
1-2 times a week
Never or nearly never
*
How often do you feel tired or
fatigued after your sleep?
Nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or nearly never
*
During your waking time, do you feel
tired, fatigued or not up to par?
Nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or nearly never
*
Have you ever nodded off or fallen
asleep while driving a vehicle?
Yes
No
*
If yes, how often does this occur?
Nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or nearly never
*
Do you have high blood pressure?
Yes
No
*
Would you like a sleep disorders
specialist to contact you if your test results are high?
Yes
No
*