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Are you 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. Use the following scale to choose the most appropriate situation:
Sitting and Reading
*
0 - Would never doze
1 - Slight chance of dozing
2 - Moderate chance of dozing
3 - High chance of dozing
Watching TV
*
0 - Would never doze
1 - Slight chance of dozing
2 - Moderate chance of dozing
3 - High chance of dozing
Sitting, inactive in a public place (ex: meeting)
*
0 - Would never doze
1 - Slight chance of dozing
2 - Moderate chance of dozing
3 - High chance of dozing
As a passenger in a car for an hour without a break
*
0 - Would never doze
1 - Slight chance of dozing
2 - Moderate chance of dozing
3 - High chance of dozing
Lying down to rest in the afternoon when circumstances permit
*
0 - Would never doze
1 - Slight chance of dozing
2 - Moderate chance of dozing
3 - High chance of dozing
Sitting and talking to someone
*
0 - Would never doze
1 - Slight chance of dozing
2 - Moderate chance of dozing
3 - High chance of dozing
In a car, while stopped for a few minutes in the traffic
*
0 - Would never doze
1 - Slight chance of dozing
2 - Moderate chance of dozing
3 - High chance of dozing
*
Indicates required field
Name
*
First
Last
Email
*
Phone Number
*
Comment
*
Submit for results
Are you feeling fatigued?
Please circle the number between 1 and 7 which you feel best fits the following statements. This refers to your usual way of life within the last week. Scoring:
1 indicates “strongly disagree” and 7 indicates “strongly agree.”
*
Indicates required field
My motivation is lower when I am fatigued
*
Select
1
2
3
4
5
6
7
Exercise brings on my fatigue
*
Select
1
2
3
4
5
6
7
I am easily fatigued
*
Select
1
2
3
4
5
6
7
Fatigue Interferes with my physical functioning
*
Select
1
2
3
4
5
6
7
Fatigue causes frequent problems for me
*
Select
1
2
3
4
5
6
7
My fatigue prevents sustained physical functioning
*
Select
1
2
3
4
5
6
7
Fatigue interferes with carrying out certain duties and responsibilities
*
Select
1
2
3
4
5
6
7
Fatigue is among my three most disabling symptoms
*
Select
1
2
3
4
5
6
7
Fatigue interferes with my work, family, or social life
*
Select
1
2
3
4
5
6
7
We will e-mail your results upon submission
Name
*
First
Last
Email
*
Phone Number
*
Comment
*
Submit for results
ARE YOU AT RISK OF SLEEP APNEA?
Please answer the following questions by checking “yes” or “no” for each one:
Snoring (Do you snore loudly?)
*
Yes
No
Tiredness (Do you often feel tired, fatigued, or sleepy during the daytime?)
*
Yes
No
Observed Apnea (Has anyone observed that you stop breathing, or gasp during sleep?)
*
Yes
No
High Blood Pressure (Do you have or are you being treated for high blood pressure?)
*
Yes
No
BMI (Is your body mass index more than 35 kg per m^2?)
*
Yes
No
Age (Are you older than 50 years?)
*
Yes
No
Neck Circumference (Is your neck circumference greater than 40cm/15.75 inches?)
*
Yes
No
Gender (Are you male?)
*
Yes
No
*
Indicates required field
Name
*
First
Last
Email
*
Phone Number
*
Comment
*
Submit for results
DO YOU HAVE TROUBLE BREATHING THROUGH YOUR NOSE?
Please help us to better understand the impact of nasal obstruction on your quality of life by completing the following survey.
Over the past ONE month, how much of a problem were the following conditions for you?
*
Indicates required field
Nasal congestion or stuffiness
*
Select
0 - Not a problem
1 - Very mild problem
2 - Moderate problem
3 - Fairly bad problem
4 - Sever problem
Nasal blockage or obstruction
*
Select
0 - Not a problem
1 - Mild problem
2- Moderate problem
3 - Fairly bad problem
4 - Severe problem
Trouble breathing through my nose
*
Select
0 - Not a problem
1 - Mild problem
2- Moderate problem
3 - Fairly bad problem
4 - Severe problem
Trouble sleeping
*
Select
0 - Not a problem
1 - Mild problem
2 - Moderate problem
3 - Fairly bad problem
4 - Sever problem
Unable to get enough air through my nose during exercises or exertion
*
Select
0 - Not a problem
1 - Mild problem
2 - Moderate problem
3 - Fairly bad problem
4 - Severe problem
Name
*
First
Last
Email
*
Phone Number
*
Comment
*
Submit for results
Home
Services
Mindful Breathing
Functional Frenuloplasty
Infant Frenectomy
>
Commonly Asked Questions by Parents
Latera
Mindful Meditation
Myofunctional Therapy
Nutrition
Sleep Endoscopy
Sleep Apnea
Sleep Hygiene
Sleep Quiz
Therapy Care Management
Patient Testimonials
Team
Breathe Associates
Breathe Ambassadors
International Ambassadors
Airway
Events/CE
2 Day Functional Sleep + Breathing / Frenuloplasty Course
Functional Frenuloplasty
Coffee CoLab
Meeting of the Minds
Lecture Files
Other Recommended Courses
Products We Love
Blog
Contact
International Patients
