At which Apnea Health clinic did you take your test?*
—Please choose an option—ChâteauguayDelsonLavalLongueuilMagogMascouchePointe-ClairePrévostSainte-ThérèseValleyfieldVaudreuil

Your full name:

Date of study:

Bedtime:

Wake up time:

Number of hours of sleep:

How long did it take to fall asleep after turning off the lights?:

How does this compare to your normal length of sleep?
—Please choose an option—Same as usualBetter than usualWorse than usual

How was your quality of sleep?
—Please choose an option—Same as usualBetter than usualWorse than usual

Did you have frequent awakenings?
—Please choose an option—YesNo

Reasons for awakenings?

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