Your name: *
Email address: (for emailing your results) *
Phone number: (optional … please call me for an appointment if my results are high)
Your weight: lbs *
Height:    *
Sitting and reading *
Watching television *
Sitting inactive in a public place such as a theater or meeting *
As a passenger in a car for an hour without a break *
Lying down to rest in the afternoon. *
Sitting and talking *
Sitting quietly after lunch (without alcohol) *
In a car while stopped in traffic *
Do you snore? *
If yes, your snoring is: *
How often do you snore? *
Has your snoring ever bothered other people? *
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? *
If yes, how often does this occur? *
Do you have high blood pressure? *
Would you like a sleep disorders specialist to contact you if your test results are high? *
How did you hear of this test? *