Do You Snore?
*
No Occurrence
Occurs Rarely
Occurs 2-4 Times Per Week
Occurs 5-7 Times Per Week
Do you stop breathing while snoring?
No Occurrence
Occurs Rarely
Occurs 2 to 4 times per week
Occurs 5 times or more per week
Labored, difficult or loud breathing at night?
*
No Occurrence
Occurs Rarely
Occurs 2 to 4 times per week
Occurs 5 to 7 times per week
Gasping for air while sleeping?
*
No Occurrence
Occurs Rarely
Occurs 2 to 4 times per week
Occurs 5 to 7 times per week
Mouth breathes while sleeping?
*
No Occurrence
Occurs Rarely
Occurs 2 to 4 times per week
Occurs 5 to 7 times per week
Mouth breathes during day?
*
No Occurrence
Occurs Rarely
Occurs 2 to 4 times per week
Occurs 5 to 7 times per week
Restless sleep?
*
No Occurrence
Occurs Rarely
Occurs 2 to 4 times per week
Occurs 5 to 7 times per week
Grinds teeth while sleeping?
*
No Occurrence
Occurs Rarely
Occurs 2 to 4 times per week
Occurs 5 to 7 times per week
Talks in sleep?
*
No Occurrence
Occurs Rarely
Occurs 2 to 4 times per week
Occurs 5 to 7 times per week
Excessive sweating while sleeping?
*
No Occurrence
Occurs Rarely
Occurs 2 to 4 times per week
Occurs 5 to 7 times per week
Wakes up at night?
*
No Occurrence
Occurs Rarely
Occurs 2 to 4 times per week
Occurs 5 to 7 times per week
Feels sleepy and/or irritable during the day?
*
No Occurrence
Occurs Rarely
Occurs 2 to 4 times per week
Occurs 5 to 7 times per week
Seasonal allergies?
*
No Occurrence
Occurs Rarely
Occurs 2 to 4 times per week
Occurs 5 to 7 times per week
Trouble focusing?
*
No Occurrence
Occurs Rarely
Occurs 2 to 4 times per week
Occurs 5 to 7 times per week
ADD/ADHD?
*
Yes
No
High Blood Pressure?
Yes
No
Full Name
*
Email
*
Phone
*