Sleep Survey | Dental Sleep Center of Chambersburg

Treating Snoring & Sleep Apnea

Contact us today to
schedule a consultation

717-830-5337

Contact us today to
schedule a consultation

717-830-5337

Name*
First Last
Phone*
Email*
Use the following scale to choose the most appropriate number for each situation:
0= would never doze or sleep
1= slight chance of dozing or sleeping
2= moderate chance of dozing or sleeping
3= high chance of dozing or sleeping
Sitting and Reading*
Watching TV*
Sitting inactive in a public place*
Being a passenger in a motor vehicle for an hour or more*
Lying down in the afternoon*
Sitting and talking to someone*
Sitting quietly after lunch (no alcohol)*
Stopped for a few minutes in traffic driving*
Height*
Weight*
Neck Size (inches)*
How many times do you usually wake up during the night?*
How long does it take you to fall asleep again?*
What time do you normally get up in the morning?*

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497 Lincoln Way East,
Chambersburg, PA 17201

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717-830-5337