Please enable JavaScript in your browser to complete this form.Snoring: Do you snore loudly?YesNoTired: Do you feel fatigued during the day?YesNoObserved: Has anyone observed you stop breathing during sleep?YesNoPressure: Do you have high blood pressure?YesNoBMI: Is your BMI greater than 35?YesNoAge: Are you older than 50?YesNoNeck Circumference: Greater than 16 inches?YesNoGender: Are you male?YesNoRate your likelihood of dozing off in the following situations: Selected Value: 0 0 = Would never doze 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozingSituation Selected Value: 0 0 = Would never doze 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozingSitting and reading Selected Value: 0 0 = Would never doze 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozingWatching television Selected Value: 0 0 = Would never doze 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozingSitting inactive in a public place Selected Value: 0 0 = Would never doze 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozingAs a passenger in a car for an hour Selected Value: 0 0 = Would never doze 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozingLying down to rest in the afternoon Selected Value: 0 0 = Would never doze 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozingSitting and talking to someone Selected Value: 0 0 = Would never doze 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozingSitting quietly after lunch Selected Value: 0 0 = Would never doze 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozingIn a car, while stopped in traffic Selected Value: 0 0 = Would never doze 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozing in likelihood rest Anything else we should know?Submit
