Mednite SleepCheck
Complete this assessment to help evaluate your sleep health. Please provide accurate information for the best results.
First Name
*
Last Name
*
Email Address
*
example@example.com
Primary Care Physician (Optional)
Date of Birth
*
-
Month
-
Day
Year
Date
Weight (pounds only)
*
Height (feet)
*
Please Select
3
4
5
6
7
8
Height (inches)
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
11
How likely are you to doze while watching TV?
*
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
How likely are you to doze while sitting and reading?
*
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
How likely are you to doze while sitting inactive in a public place?
*
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
How likely are you to doze as a passenger in a car for an hour without a break?
*
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
How likely are you to doze when lying down to rest in the afternoon?
*
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
How likely are you to doze while sitting and talking to someone?
*
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
How likely are you to doze while sitting quietly after lunch without alcohol?
*
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
How likely are you to doze while stopped in traffic for a few minutes?
*
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
ESS Total Score
*
Submit
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