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National Sleep Survey

Home National Sleep Survey

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  • Sex
  • Health Insurance

  • Do you have a Commercial Drivers License (CDL)?

  • Physician Details

    In order to facilitate your sleep apnea screening, we need to know your primary care physician. Search our database to locate and select your primary care physician. If you do not find your physician in our database, please use the Add New button to supply his or her details.

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  • Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?
  • Do you often feel tired, fatigued, or sleepy during the daytime?
  • Have you experienced episodes of falling asleep when you should be alert or sleepiness while driving?
  • Have you ever had a motor vehicle crash associated with falling asleep while driving?
  • Has anyone observed you stop breathing during your sleep?
  • Have you ever been told or noticed that you wake from sleep choking or gasping for air?
  • Do you wake frequently from sleep or wake up not feeling rested?

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation.*

  •  
  • Would never dose
  • Slight chance of dozing
  • Moderate chance of dozing
  • High chance of dozing
  1. a) Sitting and reading
    • a) Sitting and reading
    • Never
    • Slight
    • Moderate
    • High
  2. b) Watching TV
    • b) Watching TV
    • Never
    • Slight
    • Moderate
    • High
  3. c) Sitting inactive in a public place (e.g., a theater or a meeting)
    • c) Sitting inactive in a public place (e.g., a theater or a meeting)
    • Never
    • Slight
    • Moderate
    • High
  4. d) As a passenger in a car for an hour without a break
    • d) As a passenger in a car for an hour without a break
    • Never
    • Slight
    • Moderate
    • High
  5. e) Lying down to rest in the afternoon when circumstances permit
    • e) Lying down to rest in the afternoon when circumstances permit
    • Never
    • Slight
    • Moderate
    • High
  6. f) Sitting and talking to someone
    • f) Sitting and talking to someone
    • Never
    • Slight
    • Moderate
    • High
  7. g) Sitting quietly after lunch without alcohol
    • g) Sitting quietly after lunch without alcohol
    • Never
    • Slight
    • Moderate
    • High
  8. h) In a car while stopped for a few minutes in traffic
    • h) In a car while stopped for a few minutes in traffic
    • Never
    • Slight
    • Moderate
    • High

  • Do you have a family history of sleep apnea?
  • Do you have any lung or breathing problems?
  • Do you have a Pacemaker?
  • Nasal oxygen use?
  • Do you experience awakenings at night?
  • Have you ever had oral or nasal surgery?
  • Do you drink alcohol?
  • Any recent change in your intake of alcohol?

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