SLEEP ASSESSMENT AND EPWORTH SCALE
This refers to your usual way of life in recent times. Even if you haven’t done some of these things recently, try to work out how these situations would have affected you.

Please fill out our form to the best of your knowledge. It is important you answer each question as best you can.
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Email *
Your Name (First + Last) *
Phone Number *
Height *
Weight *
BMI
Gender *
Choose the appropriate number value to represent how likely you are to fall asleep in the following situations. Try to be as honest as possible.

Sitting and Reading
 *
Choose the appropriate number value to represent how likely you are to fall asleep in the following situations. Try to be as honest as possible.

Watching TV
 *
Choose the appropriate number value to represent how likely you are to fall asleep in the following situations. Try to be as honest as possible.

Sitting, Inactive in a public place (Movie theatre, meeting)
 *
Choose the appropriate number value to represent how likely you are to fall asleep in the following situations. Try to be as honest as possible.

As a passenger in a car for an hour without a break
 *
Choose the appropriate number value to represent how likely you are to fall asleep in the following situations. Try to be as honest as possible.

Lying down to rest in the afternoon when circumstances permit
 *
Choose the appropriate number value to represent how likely you are to fall asleep in the following situations. Try to be as honest as possible.

Sitting and talking to someone
 *
Choose the appropriate number value to represent how likely you are to fall asleep in the following situations. Try to be as honest as possible.

Sitting quietly after lunch without alcohol
 *
Choose the appropriate number value to represent how likely you are to fall asleep in the following situations. Try to be as honest as possible.

Driving a vehicle for two or more hours
 *
Choose the appropriate number value to represent how likely you are to fall asleep in the following situations. Try to be as honest as possible.

In a car, while stopped for a few minutes
 *
Choose the appropriate number value to represent how likely you are to fall asleep in the following situations. Try to be as honest as possible.

In a car, while stopped for a few minutes
 *
Have you been diagnosed with sleep apnea in the past?  *
Do you snore or have you been told that you snore?  *
Have you been told that you stop breathing while you sleep? *
Do you wake gasping or choking? *
Do you have high blood pressure?  *
Do you have diabetes? *
Do you have heart problems? *
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