Sleep Apnea Questionnaire

Answer the questions below, and we'll send you the results within 48 hours.

Name

Phone

Email

Please contact me with my results by:
Select Phone Email

Snoring

Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?

Select Yes No

Tired

Do you often feel tired, fatigued, or sleepy during daytime?

Select Yes No

Observed

Has anyone observed you stop breathing during your sleep?

Select Yes No

Blood Pressure

Do you have or are you being treated for high blood pressure?

Select Yes No

How sleepy are you?

How likely are you to doze off or fall asleep in the following situations?

Use the following scale to choose the most appropriate number for each situation:

0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing

Sitting and reading

Select 0 1 2 3

Watching TV

Select 0 1 2 3

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

Select 0 1 2 3

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

Select 0 1 2 3

Sitting and talking to someone

Select 0 1 2 3

Sitting quietly after a lunch without alcohol

Select 0 1 2 3

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

Select 0 1 2 3