Sleep Test

Take Our Sleep Test

Please check each statement that applies to you:

How likely are you to doze off or fall asleep in the following situations in contrast to just feeling tired?

Even if you have not done some of these things recently, try to think of how they would have affected you. Use the following scale to choose the most appropriate number for each situation:

0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

Sitting and reading:
 0 1 2 3

Watching TV:
 0 1 2 3

Sitting inactive:
 0 1 2 3

In a public place (theater or meeting):
 0 1 2 3

As a passenger in a car for an hour without a break:
 0 1 2 3

Lying down to rest in the afternoon when circumstances permit:
 0 1 2 3

Sitting and talking to someone:
 0 1 2 3

Sitting quietly after lunch without alcohol:
 0 1 2 3

In a car while stopped for a few minutes in traffic:
 0 1 2 3

Are you bothered by sleepiness under other circumstances?
 yes no
If yes, please describe:

Have you been in a car accident due to your falling asleep at the wheel?
 yes no
If yes, please describe:

Have you ever had a near miss due to your falling asleep at the wheel?
 yes no
If yes, please describe:

Have you had other types of accidents because of your sleepiness?
 yes no
If yes, please describe:

Contact Information

First Name:

Last Name:

Email Address:

Best phone # to reach you:

Best time to call:
 Morning Mid-day Afternoon

By clicking "Submit," your test will be emailed to our office staff, who will review your answers and contact you.