Have you been told you snore?
*
Yes
No
(Select all answers that apply)
Do you have any of these health conditions?
Shortness of Breath
High Blood Pressure
Coronary Artery Disease
Diabetes
Do you dream?
Yes
No
Unsure
Have you ever been diagnosed with sleep apnea?
Yes
No
How would you describe your sleep?
Insufficient - Always Tired
Very Restful
Restless / Tossing & Turning
(Select all answers that apply)
Do you experience any of the following conditions?
Insomnia
Excessive Daytime Sleepiness
Restless Leg Syndrome
Do You Work At Night?
None of the Above
Do you have a CPAP?
Yes - I Use It Every Night
Yes - But I Rarely Use It
No
How did you hear about us?
Full Name
Phone
*
Email
*
Date of birth
Gender / Pronouns
Weight (In Pounds)