Sleep Apnea Quiz North Olmsted

Get to the Bottom of Your Sleep Issues

Wondering if your snoring, daytime fatigue, or other similar symptoms are the result of untreated sleep apnea? We encourage you to take our sleep apnea quiz, linked below – it should help you get the answers you need to take your first step toward treatment!

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

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