Take Our Sleep Assessment Quiz More to Explore Meet Dr. Smith Meet Our Team What We Do Patient Stories Find CPAP Alternative Name Email Address Phone Number Age Weight Gender Have you ever had an evaluation at a sleep center? Yes No Do you have a CPAP device? Yes No Have you attempted other therapies to deal with breathing and/or snoring issues? Yes No If yes, please provide details How likely are you to doze off or fall asleep in the following situations? Sitting and reading Select One No chance of dozing Slight chance of dozing Moderate chance of dozing High chance of dozing Watching TV Select One No chance of dozing Slight chance of dozing Moderate chance of dozing High chance of dozing Sitting in a public place (e.g.: theatre, meeting or church) Select One No chance of dozing Slight chance of dozing Moderate chance of dozing High chance of dozing As a passenger in a car for an hour without a break Select One No chance of dozing Slight chance of dozing Moderate chance of dozing High chance of dozing Lying down to rest in the afternoon when circumstances permit Select One No chance of dozing Slight chance of dozing Moderate chance of dozing High chance of dozing Sitting and talking to someone Select One No chance of dozing Slight chance of dozing Moderate chance of dozing High chance of dozing Sitting quietly after lunch without alcohol Select One No chance of dozing Slight chance of dozing Moderate chance of dozing High chance of dozing In a car, while stopped for a few minutes in traffic Select One No chance of dozing Slight chance of dozing Moderate chance of dozing High chance of dozing How did you hear about us? Search EngineFamily/FriendPromotionSocial MediaRadioOther Send
