Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
I am a ____________.
*
New Patient
Existing Patient
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1. Do you snore loudly or regularly?
*
Yes
No
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2. Has your partner ever noticed you stop breathing, gasp, or choke during sleep?
*
Yes
No
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3. Do you feel excessively tired during the day, even after a full night’s sleep?
*
Yes
No
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4. Have you been diagnosed with mild to moderate obstructive sleep apnea?
*
Yes
No
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5. Have you tried CPAP but found it uncomfortable, noisy, or difficult to use consistently?
*
Yes
No
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6. Do you experience frequent morning headaches, dry mouth, or jaw discomfort?
*
Yes
No
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Additional Comments
*
*
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