Have you ever been tested for sleep apnea before or taken a sleep test?
Yes
No
Please answer the following questions by checking if answer is YES.
Do you snore?
Do you often experience daytime fatigue or sleepiness?
Has anyone seen you gasp or pause breathing in sleep?
Do you have or are you treating high blood pressure?
Is your age over 50 years old?
Do you wake up with morning headaches?
Do you wake up to use the bathroom at night?
Do you struggle with anxiety or depression?
Date of Birth
MM slash DD slash YYYY
What is your legal gender or the gender listed with your insurance carrier?
Male
Female
Your Height
Your Weight
Do you have medical insurance?
Yes
No
If you chose yes above, what is the name of your medical insurance carrier?
Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
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