Name
*
First Name
Last Name
Email
*
example@example.com
Phone
*
Do you often feel Tired, Fatigued, or Sleepy during the daytime (such as falling asleep during driving or talking to someone)?
Yes
No
Do you Snore Loudly (loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night)?
Yes
No
Has anyone Observed you Stop Breathing or Choking/Gasping during your sleep?
Yes
No
Do you have or are being treated for High Blood Pressure?
Yes
No
Is your BMI over 30?
Yes
No
Age older than 50?
Yes
No
Is your Neck circumference >40 cm?
Yes
No
Are you a male (as per sex assigned at birth)?
yes
No
Total Yes Calculate
Submit
Should be Empty: