Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
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Next
1. I have been told I stop breathing while asleep:
*
Yes
No
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2. I have fallen asleep or nodded off while driving:
*
Yes
No
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3. I’ve woken up with shortness of breath/gasping or my heart racing:
*
Yes
No
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4. I feel excessively sleepy or fatigued during the day:
*
Yes
No
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5. I snore or have been told I snore:
*
Yes
No
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6. I have had weight gain and found it difficult to lose:
*
Yes
No
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7. I have been diagnosed with high blood pressure:
*
Yes
No
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8. It takes me less than 10 minutes to fall asleep:
*
Yes
No
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9. I wake up more than 1 time per night:
*
Yes
No
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10. I wake up with headaches:
*
Yes
No
Submit
Should be Empty: