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Sleep Apnea Assessment

Personal Information

First Name

Last Name

Email

Mobile Phone Number

DOB

Please answer the following questions by checking if answer YES.

Do you snore?

Do you often feel tired, fatigued, or sleepy during the daytime?

Has anyone observed that you stop breathing or choke or gasp during your sleep?

Do you have or are you being treated for high blood pressure?

Is your BMI above 24 (Females) or 27 (Males)?

Is your age over 50 years old?

Is your neck size larger than 15" (Females) or 16.5" (Males)?

Please answer the following questions by checking if answer YES.

Female

Male

Prefer not to answer

Your Weight

Your Height

BMI Score

Would you like a member of our team to contact you about these results?

Yes

No

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.