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Take the Sleep Quiz!

If you are concerned you may have a sleep disorder, we invite you to complete the following free Sleep Quiz. Once submitted, your answers will be sent securely to our sleep disorders specialist, who will evaluate your answers and determine if you are at risk for a sleep disorder. A sleep disorders center representative will contact you within three business days with your results and recommendations.

* Indicates required information
First Name * 
Last Name * 
Phone Number * 
Email Address * 
Street Address 1 * 
Street Address 2 
City * 
State * 
Zip * 
Gender * 
Age * 
Height (ft./in.) / Weight (lbs.) * 
Neck Circumference * 
I have a history of hypertension 
Please answer the following statements related to your sleep habits and tendencies. 
My family reports that I snore loudly 
I have restless sleep or insomnia 
I am awakened by sudden choking when I sleep 
I have a sore throat or headache in the mornings 
Please respond to the following questions with the likelihood you would doze in the given situation. 
Sitting and Reading * 
Watching Television * 
Sitting inactive in a public place * 
As a passenger in a car for an hour without a break * 
Lying down to rest in the afternoon when circumstances permit * 
Sitting and Talking to Someone * 
Sitting quietly after lunch without alcohol * 
In a car stopped for a few minutes in traffic * 
Please answer the following questions regarding your current state and sleep patterns. 
Do you feel tired and irritated all of the time? * 
Do you have depression? * 
Do you experience jerking, punching or kicking while sleeping? * 
Do you fall asleep at inappropriate times? * 
Do you take a sleep aid or sedative to sleep? * 
I would like to be contacted by a sleep lab associate from: * 

I understand this "Sleep Quiz" is for screening purposes only and is not a diagnostic tool. To obtain an accurate medical diagnosis, I understand that I would need a complete sleep study and physician evaluation. * 
Authentication * 

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