Your Sleep Assessment

Do you feel tired during the day? Does your partner complain that you snore? Do you have trouble staying asleep?

If you are not getting the restful sleep you deserve, take this quick sleep test. This helpful tool is the first step in evaluating your sleep and will be used by a sleep professional in working with you to determine if you have a sleep disorder. The test is easy, comprehensive, and provides you with immediate results once you click on "submit." (* Required fields)

If your results show you may have sleep disorder, it is important to see a sleep expert. The Sleep Wellness Institute has three convenient locations where you can be evaluated by one of our sleep specialists and start the process to better sleep. We have offices located in West Allis, Mequon, Sheboygan.

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

Date of Birth (mm/dd/yyyy)*

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