Do you have Sleep Problems?

Do you have Sleep Problems?

Please complete the form below and one of our trained clinical sleep technicians will be in touch within 2-3 business days
Full Name: *
Address: *
Phone Number *
E-mail *

Confirmation Email
If you have one or more of these symptoms, you are at higher risk for having obstructive sleep apnea. If you are also overweight, have a large neck and/or have high blood pressure the risk increases even further.

If you or someone close to you answers “yes” to any of the above questions, you should discuss your symptoms with your physician or a sleep specialist.

Different treatment options exist; the appropriate treatment choice for you depends upon the severity of your apnea and other aspects of the disorder.

Untreated, obstructive sleep apnea can be extremely serious and cannot be ignored.
1. Do you snore? (If No goto question 6) *

a. Yes b. No c. Don't know
2. Is your snoring

a. Slightly louder than breathing b. As loud as talking c. Louder than talking
3. How often do you snore?

a. Almost every day b. 3-4 times per week c. 1-2 times per week d. 1-2 times per month e. Rarely or never
4. Has your snoring ever bothered other people?

a. Yes b. No c. Don't know
5. Has anyone noticed that you stop breathing during your sleep?

a. Almost every day b. 3-4 times per week c. 1-2 times per week d. 1-2 times per month e. Rarely or never
6. How often do you feel tired or fatigued after your sleep? *

a. Almost every day b. 3-4 times per week c. 1-2 times per week d. 1-2 times per month e. Rarely or never
7. During your waking time, do you feel tired, fatigued or not up to par? *

a. Almost every day b. 3-4 times per week c. 1-2 times per week d. 1-2 times per month e. Rarely or never
8. Have you ever nodded off or fallen asleep while driving a vehicle? (If No goto question 10) *

a. Yes b. No
9. How often does this occur?

a. Almost every day b. 3-4 times per week c. 1-2 times per week d. 1-2 times per month e. Rarely or never
10. Do you have high blood pressure? *

a. Yes b. No c. Don't know
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