Sleep Diagnostic & Wellness Center
Step
1
of
25
4%
General Information
Height (ft/in or cm)
(Required)
Weight (lbs or kg)
(Required)
General Information
Age
(Required)
Under 40
40–49
50–59
60+
General Information
Sex
(Required)
Male
Female
Other / Prefer not to say
Sleep Patterns
On average, what time do you usually go to bed?
(Required)
Before 9:00 PM
9:00 — 10:00 PM
10:00 — 11:00 PM
After 11:00 PM
Sleep Patterns
How long does it usually take you to fall asleep after going to bed?
(Required)
Less than 15 minutes
15 — 30 minutes
30 — 60 minutes
More than 60 minutes
Sleep Patterns
On average, how many hours of sleep do you get per night?
(Required)
Less than 5 hours
5 — 6 hours
7 — 8 hours
More than 8 hours
Sleep Environment
How would you describe the comfort of your bedroom environment?
(Required)
Very comfortable (quiet, cool, dark)
Somewhat comfortable
Often uncomfortable
Very uncomfortable
Sleep Environment
Do you use electronic devices in bed within 30 minutes of trying to sleep?
(Required)
Never
Occasionally
Most nights
Every night
Sleep Apnea Risk
Do you snore loudly (loud enough to be heard through a closed door)?
(Required)
Never
Sometimes
Frequently
Every night
Sleep Apnea Risk
Has anyone observed you stop breathing during your sleep?
(Required)
Never
Rarely
Occasionally
Frequently
Sleep Apnea Risk
Do you often wake up with headaches or a dry mouth?
(Required)
Never
Occasionally
A few times per week
Nearly every morning
Score 1 point for ≥ a few times a week.
Sleep Apnea Risk
Do you have high blood pressure (treated or untreated)?
(Required)
No
Yes
Not sure / N/A
Sleep Apnea Risk
Is your neck circumference greater than 17" (men) or 16" (women)?
(Required)
No
Yes
Not sure / N/A
Daytime Functioning
How often do you feel excessively tired or sleepy during the day?
(Required)
Never
Occasionally
Several times a week
Every day
Daytime Functioning
Do you ever doze off unintentionally (e.g., watching TV, reading, driving)?
(Required)
Never
Rarely
Sometimes
Often
Restless Legs / Movement
Do you experience an uncomfortable urge to move your legs at night (tingling, crawling sensation)?
(Required)
Never
Occasionally
A few nights per week
Almost every night
Restless Legs / Movement
Have you been told that you kick or jerk your legs in your sleep?
(Required)
Never
Rarely
Occasionally
Frequently
Lifestyle & Health
How often do you consume caffeine (coffee, soda, tea, energy drinks) after 3 PM?
(Required)
Never
Occasionally
A few times per week
Daily
Lifestyle & Health
How often do you drink alcohol in the evening?
(Required)
Never
Occasionally
A few times per week
Daily
Lifestyle & Health
Do you have any of the following medical conditions? (check all that apply)
Hypertension
Diabetes
Heart disease
Stroke history
COPD/asthma
None of the above
HTN, Diabetes, Heart disease, Stroke history, COPD/asthma
Insomnia Screening
How often do you have difficulty falling asleep at bedtime?
(Required)
Never
Rarely
Sometimes
Often
Insomnia Screening
How often do you wake up in the middle of the night and have trouble falling back asleep?
(Required)
Never
Rarely
Sometimes
Often
Insomnia Screening
How often do you wake up earlier than you would like and cannot get back to sleep?
(Required)
Never
Rarely
Sometimes
Often
Insomnia Screening
Overall, how would you rate your sleep quality over the past month?
(Required)
Very good
Fairly good
Fairly poor
Very poor
Your Results Are In
Enter your details to receive your sleep results and personalized recommendations from our Sleep Solutions team.
First Name
Last Name
Email
Get Your Sleep Results
1
Sleep Doctor
Learn about your sleep chronotype and how to manage it for better health, focus, and rest.
2
Sleep Score
See how your sleep habits and environment measure up and where you can improve.
3
Personalized Sleep Profile
Our team will review your results and send tailored guidance to help you sleep better.
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Total Score (hidden)