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Sleep Disorder Assessment

The risk factors associated with untreated sleep apnea are too serious to ignore.

Complete the following questionnaire to determine if the condition may be impacting your sleep, health and overall quality of life.


Epworth Sleepiness Scale

How likely are you to doze off while doing the following activities? Please use the following scale:

0 = never, 1 = slight, 2 = moderate, 3 = high.

Part 1

0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3

Part 2

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

Part 3

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No