Instructions: Be as accurate as possible. Read the situation then select your response by selecting the following scale to choose the most appropriate number for each situation: How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired?

0 = would never doze

1 = spght chance of dozing

2 = moderate chance of dozing

3 = high chance of dozing

1 ->United Sleep Apnea does not share your information with third parties. All information is private and will only be used in the the accepted services provided by United Sleep Apnea Services, INC. *

2 ->Please provide First name *

2 ->Please provide Last name

2 ->Please provide DOB *

3 ->Please provide an email for your results *

4 ->Optional: If you would like for us to reach out to you and discuss getting scheduled for a home sleep test.

5 ->Sitting and reading *

6 ->Watching TV *

7 ->Sitting, inactive in a public place (e.g. a theater or a meeting) *

8 ->As a passenger in a car for an hour without a break *

9 ->Lying down to rest in the afternoon when circumstances permit *

10 ->Sitting and talking to someone *

11 ->Sitting quietly after a lunch without alcohol *

12 ->In a car, while stopped for a few minutes in the trafficThis question is required. *