Patients New Patients Sleep Quiz Sleep Apnea 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 Select OneNo chance of dozingSlight chance of dozingModerate chance of dozingHigh chance of dozing Watching TV Select OneNo chance of dozingSlight chance of dozingModerate chance of dozingHigh chance of dozing Sitting in a public place (e.g.: theatre, meeting or church) Select OneNo chance of dozingSlight chance of dozingModerate chance of dozingHigh chance of dozing As a passenger in a car for an hour without a break Select OneNo chance of dozingSlight chance of dozingModerate chance of dozingHigh chance of dozing Lying down to rest in the afternoon when circumstances permit Select OneNo chance of dozingSlight chance of dozingModerate chance of dozingHigh chance of dozing Sitting and talking to someone Select OneNo chance of dozingSlight chance of dozingModerate chance of dozingHigh chance of dozing Sitting quietly after lunch without alcohol Select OneNo chance of dozingSlight chance of dozingModerate chance of dozingHigh chance of dozing In a car, while stopped for a few minutes in traffic Select OneNo chance of dozingSlight chance of dozingModerate chance of dozingHigh chance of dozing Send