How Well Do You Sleep?

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 *

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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 *

Exercise brings on my fatigue *

I am easily fatigued *

Fatigue Interferes with my physical functioning *

Fatigue causes frequent problems for me *

My fatigue prevents sustained physical functioning *

Fatigue interferes with carrying out certain duties and responsibilities *

Fatigue is among my three most disabling symptoms *

Fatigue interferes with my work, family, or social life *

We will e-mail your results upon submission

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 *

Nasal blockage or obstruction *

Trouble breathing through my nose *

Trouble sleeping *

Unable to get enough air through my nose during exercises or exertion *

Name *

First

Last

Email *

Phone Number *

Comment *

Submit for results