Email: A value is required.Invalid format.
Please indicate how likely you are to doze off or fall asleep in the following situations:
Height: Select Feet 3 4 5 6 7 Please select a valid item. Please select an item. Feet Please select a valid item. Please select an item. Select Inches 0 1 2 3 4 5 6 7 8 9 10 11 Please select a valid item.Please select an item.Please select a valid item. InchesPlease select an item.
Weight A value is required.Minimum number of characters not met.
Neck Circumference Choose One < 12" 12 13 14 15 16 17 18 > 18 Please select a valid item. Please select an item.Please select a valid item. Please select an item.
Sex: Choose One Female Male Please select a valid item. Please select an item.
Have you gained at least 15 pounds in the last 6 months? Choose One Yes No Please select a valid item. Please select an item.
Have you previously been diagnosed with Sleep Apnea? Choose One Yes No Please select an item.
If Yes: When were you diagnosed? (approximate month/year)
Were you put on CPAP Therapy for treatment? Yes No
Are you still using your CPAP every night? Yes No
Any comments or observations regarding your sleep apnea and/or snoring that you would like to share with the doctor:
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