Sleep Quiz

Name

Email Address

Phone Number

Age

Weight

Gender

Have you ever had an evaluation at a sleep center? Yes No

Do you have a CPAP device? Yes No

Have you attempted other therapies to deal with breathing and/or snoring issues? Yes No

If yes, please provide details

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

Sitting and reading

Watching TV

Sitting in a public place (e.g.: theatre, meeting or church)

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 lunch without alcohol

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