On a scale of 0-3: Do you often feel sleepy or struggle to stay awake while watching TV? *

0

1

2

3

On a scale of 0-3: Do you ever doze off while sitting quietly, reading, or relaxing? *

0

1

2

3

On a scale of 0-3: Do you feel unusually sleepy during meetings, at work, or while sitting inactive? *

0

1

2

3

On a scale of 0-3: Have you ever nodded off or struggled to stay awake while riding in a car as a passenger? *

0

1

2

3

On a scale of 0-3: Do you regularly feel like you need a nap during the day, even after a full night’s sleep? *

0

1

2

3

On a scale of 0-3: Do you ever find yourself fighting to keep your eyes open or losing focus because you’re so tired? *

0

1

2

3

Have you been told you snore loudly? *

Yes

No

Have you been gaining weight or having issues losing weight? *

Yes

No

Do you find it difficult to maintain focus during your usual day-to-day? *

Yes

No

Have you seen a doctor before for sleep-related issues? *

Yes

No

Do you have medical insurance? Either from your employer or Medicaid? *

Yes

No

First Name *

Last Name *

Email *

Phone *

Postal Code *