Learn More About Your Sleep Quality
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SLEEP QUIZ
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Date of Birth
*
Month
January
February
March
April
May
June
July
August
September
October
November
December
Gender
*
Male
Female
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Your Weight
*
(in lbs)
*
Your Height
*
Feet
*
Inches
*
Neck Size
*
(in Inches)
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COMORBIDITIES
*
Have you been diagnosed or treated for any of the following conditions?
High blood pressure
Stroke
Heart disease
Diabetes
Depression
Sleep Apnea
Lung disease
Nasal oxygen use
Insomnia
Restless legs syndrome
Narcolepsy
Morning Headaches
Sleep Medication
Pain Medication e.g. vicodin, oxycontin
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Epworth Sleepiness Scale
How likely are you to doze off or fall asleep (more than just feeling tired) in the following situations?
Try to think about how these things would typically affect you.
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Epworth Sleepiness Scale
Sitting and reading
*
Would Never Doze
Slight Chance Of Dozing
Moderate Chance Of Dozing
High Chance Of Dozing
Watching TV
*
Would Never Doze
Slight Chance Of Dozing
Moderate Chance Dozing
High Chance Of Dozing
Sitting, inactive, in a public place (theater, meeting, etc)
*
Would Never Doze
Slight Chance Of Dozing
Moderate Chance Dozing
High Chance Of Dozing
As a passenger in a car for an hour without a break
*
Would Never Doze
Slight Chance Of Dozing
Moderate Chance Dozing
High Chance Of Dozing
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Epworth Sleepiness Scale
Lying down to rest in the afternoon when circumstances permit
*
Would Never Doze
Slight Chance Of Dozing
Moderate Chance Dozing
High Chance Of Dozing
Sitting and talking to someone
*
Would Never Doze
Slight Chance Of Dozing
Moderate Chance Dozing
High Chance Of Dozing
Sitting quietly after lunch without alcohol
*
Would Never Doze
Slight Chance Of Dozing
Moderate Chance Dozing
High Chance Of Dozing
In a car, while stopped for a few minutes in traffic
*
Would Never Doze
Slight Chance Of Dozing
Moderate Chance Dozing
High Chance Of Dozing
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Frequency
On average in the past month, how often have you snored or been told that you snored?
*
Never
Rarely
Sometimes
Frequently
Almost always
Do you wake up choking or gasping?
*
Never
Rarely
Sometimes
Frequently
Almost always
Have you been told that you stop breathing in your sleep or wake up choking or gasping?
*
Never
Rarely
Sometimes
Frequently
Almost always
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Calculating Your Result Now
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First Name
*
Last Name
*
Email Address
*
Phone Number
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