Is Your Sleep Keeping You Up At Night?
Take the sleep quiz to find out!
Back
Take The Quiz
Do you snore?
YES
NO
Back
Next
Do you spend the most time sleeping on your back, side, or stomach?
Back
Side
Stomach
Back
Next
Do you have GERD or heartburn regularly at night?
YES
NO
Back
Next
Have you ever been diagnosed with sleep apnea?
YES
NO
Back
Next
How long ago was your Sleep Study (either at home or in-lab)
Within the last year
Over a year ago
A long time ago
Back
Next
Do you have a CPAP Machine?
YES
NO
Back
Next
How often do you use your CPAP Machine?
All night, every night
A few hours each night
A couple times per week
Once a week
Rarely
Never
Back
Next
How would you rate your CPAP experience in the following categories?
Very Negative
Negative
Neutral
Positive
Very Positive
Comfort
Noise
Portability/Travel
Sleep Quality
Ease of Use
Overall
Back
Next
Do you have (or think you have) TMJ, Chronic Headaches or Jaw Pain?
YES
NO
Back
Next
Do you have dentures or missing teeth?
YES, Dentures
YES, Missing Teeth
NO
Back
Next
Do you have braces or any major dental work pending?
YES, Braces
YES, Major Dental Work Pending
NO
Back
Next
STOP-BANG Questionnaire
This is a questionnaire used by physician to screen for potential sleep apnea.
Please answer to the best of your ability
YES
NO
Do you snore?
Do you often feel tired, fatigued, or sleepy during the day?
Has anyone observed you stop breathing during your sleep?
Do you have or are you being treated for high blood pressure?
Is your BMI more than 35kg per m2?
Are you older than 50?
Is your neck circumference greater than 40cm?
Are you male?
Back
Next
Epworth Sleepiness Scale
0 = Would Never Feel Fatigued, 1 = Slight Chance of Fatigue, 2 = Moderate chance of Fatigue, 3 = High Chance of Fatigue
How likely would you be to feel fatigued in the following situations?
0
1
2
3
Sitting and reading
Watching TV
Sitting in a public place
Sitting in a car as a passenger without a break
Lying down to rest
Sitting and talking with someone
Sitting quietly after lunch without alcohol
In a car while stopped for a few minutes in traffic
Back
Next
Fantastic! We'll send you your results!
Please add your contact information below. We'll email you your results and one of our team members will reach out to you to review your results.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Submit
Should be Empty: