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When You Need Help
Your name: *
Email address:
(for emailing your results)		 *
Phone number:
Address:
Your zip code: *
Your weight: lbs *
Height:    *

Please answer these questions to help us gauge your risk of Sleep Apnea:
Sitting and reading *
Watching television *
Sitting inactive in a public place such as a theater or meeting *
As a passenger in a car for an hour without a break *
Lying down to rest in the afternoon. *
Sitting and talking *
Sitting quietly after lunch (without alcohol) *
In a car while stopped in traffic *
Do you snore? *
If yes, your snoring is: *
How often do you snore? *
Has your snoring ever bothered other people? *
Has anyone noticed that you quit breathing during your sleep? *
How often do you feel tired or fatigued after your sleep? *
During your waking time, do you feel tired, fatigued or not up to par? *
Have you ever nodded off or fallen asleep while driving a vehicle? *
If yes, how often does this occur? *
Do you have high blood pressure? *
Would you like a sleep disorders specialist to contact you if your test results are high? *

 

Since a great number of people suffer from sleep disorders without getting treated, anyone who suspects they may have a sleep disorder should seek help. Sleep deprivation is very serious and can affect growth in children, weight loss in adults, and the functioning of the body's organs. It is a significant detriment to good health.