Free Assessment Please enable JavaScript in your browser to complete this form.Who are you completing this sleep assessment for? *Taking this assessment for myselfTaking this assessment for my friend/family Phone numberTems and Conditions *By starting the Online Sleep Assessment, our Terms and Conditions will apply. We will collect and use your personal and health information to provide you with the Online Sleep Assessment results. For more information, please refer to our Privacy Policy and Collection Notice.What is your height in cm? *Enter your details in the boxes belowWhat is your weight in kg? *Enter your details in the boxes belowWhat is your gender? *MaleFemalePrefer not to anwerWhich year were you born? *Enter your details in the boxes below (Years)How would you describe your sleep (pick most applicable)? *LightCould Be BetterDistrurbDeepGreatTerriabeWhat has been your key motivation to improve your sleep issues? (You can choose multiple) *Partner wants me to stop snoringLow energy and fatigueOngoing health issues or riskDoctor's recommendationWork productivity & performance issuesSudden eventAny otherWhat do you want to change about your sleep? (pick only 1) *Fall asleep fasterFall asleep without sleep medicationSleep all through the nightWake up earlierTreat my snoringHave more daytime energyImprove your sleep apnea treatmentOtherHave you ever discussed Sleep related issues with any of these? (You can choose multiple) *DoctorPartnerFriendRelativeOtherDo you use a wearable fitness tracker or similar health tracking device? *YesNoOn average, how many hours of sleep do you get each night? *Less than 5 hours5 - 7 hours7 - 9 hoursMore than 9 hoursHow satisfied do you feel about your current sleep? *Very SatisfiedSatisfiedModerately SatisfiedDissatisfiedVery DissatisfiedDuring your sleep, which of the following applies to you? Select all that apply. *I have difficulty falling asleepI have difficulty staying asleepI often wake up during the nightI wake up earlier than desiredNone of the aboveOn average, do you experience these symptoms more than 3 times a week? *YesNoHave you experienced these symptoms for more than 3 months? *YesNoDo you feel that your sleep problems are interfering with your daily functioning? *Not at all interferingA littleSome WhatMuchVery much interferingHave you been told you snore? *YesNoDo you sleep next to someone who snores? *YesNoDo you wake with headaches in the morning? *YesNoEven after sleeping through the night, do you feel sleepy during the day? *YesNoHow sleepy do you usually feel during the day? *ExtremelyModeratelyVerySlightlyHave you ever been told you hold your breath while sleeping? *YesNoHow often have you had trouble sleeping because of pain? *NeverLess than once a weekOnce a weekThree or more times a weekHave you ever experienced waking up coughing? *YesNoDo you ever wake gasping for breath? *YesNoDo you have high blood pressure or are taking medicine to treat it? *YesNoDo you experience heartburn or acid reflux, or take medication to treat it? *YesNoHave you been diagnosed with (or suffer from) any of these conditions? *DiabetesCOPD or any respiratory disorderHeart failureChronic PainStrokeObesityDepression or mood disorderThyroid conditionsNoneDo you wake up with an aching jaw, or ever been told that you grind your teeth during sleep? *YesNoNot sureDo you sometimes feel that you have to move your legs to make them feel comfortable? *YesNoNot SureHave you heard of a common disorder called Sleep Apnea? *YesNoDo you believe that untreated Sleep Apnea has risk on your overall health? *YesNoHave you ever been diagnosed with Sleep Apnea? *YesNoIf you recall, what was your diagnosed Apnea Hypopnea Index (AHI)? *AHI <5AHI >5<15AHI >15<30AHI>30Don't recallSince your diagnosis, have you tried CPAP?YesNoAre you currently using CPAP?YesNoWould you be interested in speaking to a Eugene to discuss options to improve your sleep?YesNoName *FirstLastTelephone NumberEmail *Submit
