Wisconsin sleep apnea treatment center

Sleep Apnea Risk Assessment

Take this interactive test to help determine your sleep apnea risk. The test combines several assessment tools used by sleep professionals in working with patients who have sleep disorders. The test is easy, comprehensive, and provides you with immediate results once you click on "submit." (* Required fields)

What are you currently having trouble with?
(Check all that apply)
:




Other:
Do you have difficulty falling asleep, staying asleep *
or waking up too early that affects the way  
you feel or function in the day?  
:
Do you struggle with shift work? * :
Do you feel an urge to move your legs that *
interferes with your sleep most nights?  
:
Do you struggle to stay awake during day hours * :
Are you receiving treatment for a sleep disorder but *
you are not completely satisfied?  
:
Do you snore? * :
Has anyone noticed that you quit breathing *
during your sleep?  
:
Have you ever nodded off or fallen asleep *
while driving a vehicle?  
:

Chance of dozing in this situation

Sitting and reading * :
Watching television * :
Sitting inactive in a public place such as a theater or meeting * :
As a passenger in a car for an hour without a break * :
Lying down to rest in the afternoon * :
Sitting and talking * :
Sitting quietly after lunch (without alcohol) * :
In a car while stopped in traffic * :

Other Health Information

Gender * :
Weight * :
Height * : Feet Inches
Age * :
Neck Circumference  :
Do you have high blood pressure? * :

Please provide your contact information below, so we can contact you regarding your assessment results.

First Name * :
Last Name * :
Primary Care Doctor  :
Insurance Type  :
How did you hear of this test? * :
Email * :  
Phone  :
Best time to contact you  :
Best appointment time  :
Address  :
City  :
State  :
Zip Code  :