Do you snore loudly?
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Yes
No
Do you feel tired, fatigued or sleepy during the day?
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Yes
No
Has anyone observed you stop breathing or choking/gasping during your sleep?
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Yes
No
On an average day, how likely are you to nod off or fall asleep while sitting and reading, in contrast to just feeling tired?
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1 - Would never nod off
2 - Slight chance of nodding off
3 - Moderate chance of nodding off
4 - High chance of nodding off
On an average day, how likely are you to nod off or fall asleep while watching TV, in contrast to just feeling tired?
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1 - Would never nod off
2 - Slight chance of nodding off
3 - Moderate chance of nodding off
4 - High chance of nodding off
On an average day, how likely are you to nod off or fall asleep while sitting, inactive in a public place (e.g., in a meeting, theater, or dinner event), in contrast to just feeling tired?
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1 - Would never nod off
2 - Slight chance of nodding off
3 - Moderate chance of nodding off
4 - High chance of nodding off
On an average day, how likely are you to nod off or fall asleep as a passenger in a car for an hour or more without stopping for a break, in contrast to just feeling tired?
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1 - Would never nod off
2 - Slight chance of nodding off
3 - Moderate chance of nodding off
4 - High chance of nodding off
On an average day, how likely are you to nod off or fall asleep lying down to rest when circumstances permit, in contrast to just feeling tired?
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1 - Would never nod off
2 - Slight chance of nodding off
3 - Moderate chance of nodding off
4 - High chance of nodding off
On an average day, how likely are you to nod off or fall asleep while sitting and talking to someone , in contrast to just feeling tired?
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1 - Would never nod off
2 - Slight chance of nodding off
3 - Moderate chance of nodding off
4 - High chance of nodding off
On an average day, how likely are you to nod off or fall asleep while sitting quietly after a meal without alcohol, in contrast to just feeling tired?
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1 - Would never nod off
2 - Slight chance of nodding off
3 - Moderate chance of nodding off
4 - High chance of nodding off
On an average day, how likely are you to nod off or fall asleep in a car, while stopped for a few minutes in traffic or at a light, in contrast to just feeling tired?
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1 - Would never nod off
2 - Slight chance of nodding off
3 - Moderate chance of nodding off
4 - High chance of nodding off
First Name
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Last Name
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Cell Phone
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Email
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