AvantSleep
About Us
Sleep Apnea
Locations
Contact
Sleep Consultation
Sleep Disorder Quiz
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Your Information
Age
*
Gender
*
Male
Female
Height & Weight Version
*
English Version
Metric Version
Height
*
ft
Height
*
in
Weight
*
lb
Height
*
cm
Weight
*
kg
Symptoms & Medical History
Please check all symptoms that apply:
*
Snoring
Awakening during sleep gasping/choking/racing heart
Difficulty falling sleep
Difficulty staying asleep
Tired during the day
Leg discomfort that prevents me from falling asleep
Unusual behaviour during sleep
Frequent, disturbing nightmares
Other
Please tell us a little about your medical history:
High blood pressure or taking medications for high blood pressure
High cholesterol
Diabetes
Past heart attack
Atrial Fibrillation
Stroke
Chronic Pain
Lung disease
Depression/Anxiety
Tonsils removed
Other
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Your Sleep Schedule
How long does it usually take you to fall asleep?
Less than 30 min
30-60 min
More than 60 min
How often do you wake up during the night?
None
Once
Twice
More than twice
Do you have problems falling back asleep after waking up?
Yes
No
How many hours of sleep do you usually get per night?
Do you take anything to help you sleep?
Yes
No
Please tell us about your usual daytime function:
Full of energy
Tired in the morning but well during the day
Moderate energy, enough for important activities and some other activities
Low energy, enough for important activated but that’s all
No energy, struggle to get through my important activities and often take long naps
Other symptoms:
I am often worried/anxious/planning/problem solving before bed
I often toss and turn at night
I frequently have a headache when I wake up
I wake up to use the washroom more than once per night
I’ve been told I stop breathing at night
I talk/walk/act out my dreams in my sleep
I feel like I am able to fall asleep anywhere
Thank you for completing the Sleep Disorders quiz, please provide us with the following contact information and the clinic representative will contact you the following business day.
Name
First
Last
Email
Telephone
Nearest Sleep Centre
*
Burnaby
Calgary - Chinook
Calgary - Crowfoot
Calgary - Evergreen
Campbell River
Dartmouth
Dieppe
Edmonton - South
Edmonton - West
Fredericton
Maple Ridge
Moncton
North Vancouver
Penticton
Prince George
Sidney
Vancouver
Langford