Helping  you  get  the   sleep  you  deserve

How likely are you to doze off or fall asleep in the following situations, as compared to just feeling tired? Even if you have not done some of these things recently, try to answer how you think you would be affected? Use the following scale: 0 = would never doze 1 = slight chance 2 = moderate chance 3 = high chance of dozing
Type of Sleep Study Requested:
History and physical: (Please check any of the following that apply):
Referring Physician: *Please attach clinical notes and recent sleep study*

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