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Sleep Questionnaire
Take our online self assessment to see if you are at an increased risk for a sleep disorder.
11
Questions
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Language
English (US)
1
Do you snore loudly, loud enough to be heard through closed doors?
*
This field is required.
Please Select
Yes
No
Not sure
Please Select
Please Select
Yes
No
Not sure
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2
Do you snore loudly, loud enough to be heard through closed doors?
*
This field is required.
YES
NO
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3
Do you often feel tired, fatigued or sleepy during the day?
*
This field is required.
Please Select
Yes
No
Please Select
Please Select
Yes
No
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4
Do you often feel tired, fatigued or sleepy during the day?
*
This field is required.
YES
NO
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5
Has anyone observed you stop breathing during your sleep?
*
This field is required.
Please Select
No
Yes
Please Select
Please Select
No
Yes
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6
Has anyone observed you stop breathing during you sleep?
*
This field is required.
YES
NO
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7
Do you have or are you being treated for high blood pressure?
*
This field is required.
Please Select
Yes
No
Please Select
Please Select
Yes
No
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8
Do you have or are you being treated for high blood pressure?
*
This field is required.
YES
NO
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9
Height in inches
*
This field is required.
inches
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10
Weight
*
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11
Body Mass Index Calculator
BMI calculator
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12
Is your BMI, calculated on the previous screen, greater than 35.0?
*
This field is required.
Click PREVIOUS to view calculation again
YES
NO
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13
Age >50 years:
*
This field is required.
Please Select
Please Select
Please Select
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14
Are you over the age of 50?
*
This field is required.
YES
NO
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15
Is your neck circumference >17 inches for men or >16 inches for women?
*
This field is required.
Please Select
Yes
No
Please Select
Please Select
Yes
No
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16
Is your neck circumference >17 inches for men or >16 inches for women?
*
This field is required.
YES
NO
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17
Gender
*
This field is required.
Male
Female
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18
Does patient have contraindications for HSAT?
YES
NO
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19
Total Number of 'yes' answers
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20
Calculation
total number of 'yes' answers
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21
Do you have or are you being treated for any of the following?
Please check any that apply
COPD
Neuromuscular Disease
Heart Failure
Trouble handling small objects
Currently on Oxygen
Have a pacemaker device
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22
Please submit your name and email address for the results of the questionnaire
*
This field is required.
*Chung F et al Brit J Anaesth 2012;108:768-75
Name
Please enter your email
Please list the state where you live so we can provide a physician licensed in your state
Yes
No
Yes
Yes
No
I agree to receive the results of this sleep questionnaire and sleep information via email
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