Sleep Study Quiz

Sleep Study Quiz

Find out if you have a sleep disorder.

By filling out the below questionnaire, we can determining your risk for Obstructive Sleep Apnea (OSA) and provide you further information about Little Company of Mary's Sleep Disorders Center. If you answer yes to any of the following questions, you may already be suffering from from OSA and should speak directly with a Sleep Center representative by selecting a contact method below or calling the Center directly at 708.423.7378. This is your first step to seizing your Z's.

 

This questionnaire is a sleep screening tool and should not be regarded as medical advice.  By completing this form you authorize Little Company of Mary's Sleep Disorders Center to provide you further information about the Center and/or contact you if you have chosen that method.  

 

Required fields are marked with an asterisk *

First Name *
Last Name *
Email Address *
Address
City
State
Zip
Phone Number
Preferred Method For Receiving Further Information
Height
Weight
Age *
Do you snore loudly? *
Yes No
Does your snoring wake you up at night? *
Yes No
Does your bedroom partner complain about your snoring? *
Yes No
Does your bedroom partner wake you up at night because you are choking or gasping? *
Yes No
Do you have a dry mouth in the morning? *
Yes No
Do you feel tired when you wake up? *
Yes No
Do you all asleep during the day when you should be awake? *
Yes No
Do you fall asleep when watching TV, reading, or driving? *
Yes No
Have you ever fallen asleep driving? *
Yes No
Are you more forgetful? *
Yes No
Are you having trouble concentrating? *
Yes No
Do you have high blood pressure? *
Yes No
Do you wish to be contacted directly by a Sleep Center Representative? *
Yes No
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