0 = Never 1 = Slight Chance 2 = Moderate Chance 3 = Very Likely
How likely are you to Doze off in the Following Situations?
Snoring may have a significant impact on you and your family's lives
Sitting and Reading
How often are you told you snore?
Watching TV
Does your snoring affect your bed partner?
Sitting in a Public Place
Does your snoring affect others in the house?
Riding in a Car, Train or Plane
Lying Down in the afternoon
Sitting & Talking
Sitting quietly after drinking alcohol
In a car stopped for traffic
Have you been told you to stop breathing between snores?
Have you been suddenly awakened by your own snoring?
Do you awaken from sleep with a gasping or choking sensation?
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SLEEPCARE CENTERS, INC.
1-800-SLEEP RX
Centers for the Diagnosis of Sleep Disorders
MAIN BUSINESS OFFICE:
130 Gaither Drive, Suite 124
Mt. Laurel, NJ 08054
info@sleepcarecenter.com