Have you ever been told you snore? *

Yes

No

Have you ever been told you gasp, choke, or stop breathing when sleeping? *

Yes

No

Ever catch yourself nodding off when you'd rather stay awake? *

Yes

No

Do you often wake up feeling refreshed? *

Yes

No

Do you breathe through your mouth or nose while sleeping? *

Mouth

Nose

Do you breathe through your mouth during the day? *

Yes

No

Do you grind or clinch your teeth while sleeping? *

Yes

No

Do you talk in your sleep? *

Yes

No

Do you sweat a lot while sleeping? *

Yes

No

Do you wake up at night often? *

Yes

No

Sometimes

Do you have seasonal alergies? *

Yes

No

Do you have trouble focusing? *

Yes

No

ADD/ADHD? *

Yes

No

High Blood Pressure? *

Yes

No

Full Name *

Email *

Phone *

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