Do you snore loudly (louder than talking or loud enough to be heard through closed doors)? *

Yes

No

Do you often feel tired, fatigued, or sleepy during the day? *

Yes

No

Has anyone observed you stop breathing or gasp during sleep? *

Yes

No

Have you had, or are you currently being treated for, high blood pressure? *

Yes

No

Are you over 50 years old? *

Yes

No

Is your BMI (body mass index) greater than 35? *

Yes

No

Full Name *

Email *

Phone *

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