Do you snore?  * Yes   No   Don't Know
Has your snoring ever bothered other people? * Yes   No   Don't Know
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? * Yes   No
Chance of dozing in this situation  
Sitting and reading: * Never   Slight   Moderate   High
Watching television: * Never   Slight   Moderate   High
Sitting inactive in a public place such as a theater or meeting: * Never   Slight   Moderate   High
As a passenger in a car for an hour without a break: * Never   Slight   Moderate   High
Lying down to rest in the afternoon: * Never   Slight   Moderate   High
Sitting and talking: * Never   Slight   Moderate   High
Sitting quietly after lunch (without alcohol): * Never   Slight   Moderate   High
In a car while stopped in traffic: * Never   Slight   Moderate   High
Weight: * lbs
Height: *  
Do you have high blood pressure? * Yes   No
Would you like a sleep disorders specialist to contact you if your test results are high? * Yes   No
How did you hear of this test? *
Gender: *
First name: *
Last name:  *
Email address: (for emailing your results) *
Phone number: (please call me with more information)
Best time to call:
Address:
City:
State:
Zip code: *