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Sleep Quality Assessment

If you're concerned about the quality of your sleep, if you snore or suffer from sleep apnea, please take the following quick quiz to quickly determine whether you should consider sleep apnea treatment.

Sleepiness Quiz

How likely are you to doze off or fall asleep in the situations described below, in contrast to just feeling tired?

Please note that this refers to your usual way of life in the past few weeks or months. Even if you haven�t done some of these things recently try to work out how they would have affected you.

0 = would never doze, 3 = high chance of dozing

Situation

Sitting and reading

Chance of Dozing
Watching TV

Chance of Dozing
Sitting, inactive in a public place (e.g. a theater or a meeting)

Chance of Dozing
As a passenger in a car for an hour without a break

Chance of Dozing
Lying down to rest in the afternoon when circumstances permit

Chance of Dozing
Sitting and talking to someone

Chance of Dozing
Sitting quietly after a lunch without alcohol

Chance of Dozing
In a car, while stopped for a few minutes in the traffic

Chance of Dozing

Name:

First

Last
Phone Numbers:

Day-Time Phone Number

Alternate Phone Number
Email Address:

Valid Email Address
Age:
Gender

Choose one

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Sleep Quality Assessment

Sleepiness Quiz

Sitting and reading

Watching TV

Sitting, inactive in a public place (e.g. a theater or a meeting)

As a passenger in a car for an hour without a break

Lying down to rest in the afternoon when circumstances permit

Sitting and talking to someone

Sitting quietly after a lunch without alcohol

In a car, while stopped for a few minutes in the traffic

Name:

Phone Numbers:

Email Address:

Age:

Gender

For Security Purposes, Please Enter the Code Below:

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