Sleep Apnea Survey

Name *

First

Last Name *

Last

Phone *

Email *

1. How likely are you to doze off or fall asleep while sitting and reading? *

1- Slight chance of dozing

2 - Moderate chance of dozing

3 - High chance of dozing

How likely are you to doze off or fall asleep while watching TV? *

1 - Slight chance of dozing

2 - Moderate chance of dozing

3 - High chance of dozing

How likely are you to doze off or fall asleep while sitting inactive in a public area? (Theater, meeting, etc.) *

1 - Slight chance of dozing

2 - Moderate chance of dozing

3 - High chance of dozing

How likely are you to doze off or fall asleep in the car as passenger for 1 hour with no breaks? *

1 - Slight chance of dozing

2 - Moderate chance of dozing

3 - High chance of dozing

How likely are you to doze off or fall asleep while sitting and talking to someone? *

1 - Slight chance of dozing

2 - Moderate chance of dozing

3 - High chance of dozing

How likely are you to doze off or fall asleep in a car, stopped in traffic? *

1 - Slight chance of dozing

2 - Moderate chance of dozing

3 - High chance of dozing

How likely are you to doze off or fall asleep sitting quietly after lunch, no alcohol? *

1 - Slight chance of dozing

2 - Moderate chance of dozing

3 - High chance of dozing

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