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Patient Questionnaire
52
Questions
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1
Patient URN
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2
Who Is Completing This Questionnaire?
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Patient
Spouse
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Friend
Other
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3
Why Is Patient Unable To Complete?
Patient physically unable
Patient cognitively impaired
Patient clinically unable to be disturbed
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Other
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4
Who Is Completing The Questionnaire?
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5
Patient Name
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First Name
Last Name
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6
Date of Birth
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Month
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Day
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1929
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1922
1921
1920
Year
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7
Height & Weight
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Please enter height in feet and inches and weight in lbs.
Feet
Inches
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8
Recent Weight Change
Have you recently lost/gained weight?
No, my weight has not changed
Yes, I gained weight
Yes, I lost weight
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9
Weight Change Amount
You recently lost/gained weight. Please enter your weight in pounds.
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10
Primary Care Physician
Please select your primary care physician. If not listed, please enter.
Please Select
Aaron John
Aaron Joshua
Abad Remedios
Abate Karen
Abboud Semaan
Abdulrazzaq Shaakira Lateefa
Abraham Saumya
Abrams Cella
Abrams Jerome
Acevedo Anastazia
Achu Davi - Lue
Adabala Ramesh
Adair Robert
Adams Gregory
Addogoh Bernard
Adeleke Kamar
Adkins Prentiss
Afilaka Olasumbo
Afzal Mohammed
Agard Reynold
Agarwal Ekta
Aggarwal Atishi
Aguillon H Paul
Aguirre Geoffrey
Ahmad Sajjad
Ahmed Rizwana
Akbari Marjaneh
Akinruli Omowunmi
Akouegnon Florence
Alarcon Fabricio
Alberici Anna
Alberico Rarig Terry Lynn
Albizu Glenda
Alderson Gina
Alecxih Korie
Alexander Katie
Alfieri Anthony
Alfieri Paul
Ali Hakim
Aljunaidi Islam
Allen Abby
AluParks Nicole
Alvarado Carol
Amara Sathurukan
Amick Mart
Amjad Faria
Amoako Agyenim
Ampadu Franklin
Andersen Kathleen
Anderson Nina
Anderson Patrick
Andrews Meghan
Angeloni John
Angkeow Piamsook
Ankomah Patience
Annas Darlene
Anthony Harry
Antoniou Maria
Aponte Lourdes
Archbald Anne
Arena Louis
Arias Ercilia
Arnold Lisa
Arredondo Matthew
Arshad Nadia
ASHBURN MICHAEL
Ashkenase Lindsay
Ashley Linda
Asif Muhammad
Asif Nouman
Asija Amit
Assadi Jordan
Atallah Chalita
Athar Muhammad
Atlas Douglas
Attalah Chalita
August David
Austria Jose
Aviado Domingo
Avigliano Imeliza
Avinash Chandra
Aye Thuya
Ayers Christina
Azarcon Constantine
Baag Dongho
Babu P G V
Bachman Emelia
Bacon Alfred
Badillo Rene
Bagas Suzanne
Bahtiarian Gregory
Bailey Latrina
Bains Apar
Baker Bernadette
Baker Courtney
Baker JoAnn
Bakshi Gita
Balaraman Shanthi
Balasubramanian Sriram
Baldi Christopher
Ball Willliam
Banerjee Audreesh
Banfield Flavee
Banker Karen
Banzon Victor
Barber Catherine
Barbouletos Sareen
Barcena Luis
Barekatain Armin
Barham Kalleen
Barkasy Michael
Barmpouletos Dimitrios
Barnes Cedric
Barnett-Smith Rhoneise
Barone-Carroll Angela
Barrett Carolyn
Barringer John
Barriocanal Linda
Barrow Shannon
Barry Paula
Bartels Lisa
Barth Patrick
Bartolo Linda
Barwick Robert
Batchelor Christopher
Bates Tyler
Batra Vikas
Bauman David
Baumgardner Loretta
Baxter Jessica
Bay Mihee
Beals Paul
Beams Marjorie
Bean Sidney
Beebe James
Beiso Roberta
Belicena Maricar
Bell Rodney
Bellini Lisa
Benson Brian
Bercaw David
Bergamini Paula
Berger Ronald
Beringer Holly
Berkowitz Steven
Bernstein Emily
Berry Shanna
Beste Gary
Bhalla Meenakshi
Bhamidipati Vijaya
Bhattacharya Sangeeta
Bianchetta Tony
Bianchi Alessandro
Bianchi Alex
Biasotto Nicholas
Bickel Kim
Billig-Figura Kelly
Billon John
Bilski Beth Ann
Bilyk Jurij
Bin Wei
Biniaurishvili Raoul
Binkley Jean
Birch David
Bittner-Fagan Heather
Blackburn Mari
Blackiston Brenda
Blacklock Curt
Blake Carol
Blattner Matthew
Block Daniel
Bloom Robert
Blumberg Stephen
Bober Michael
Bober Mitchell
Bolinger Cheryl
Bonavente Arnulfo
Bonerigo Sarah
Bonner Hugh
Boon Maurits
Boone Stephen
Bora Saikia Pinky
Borer Mark
Borodulia Nicholas
Bostick Amanda
Boudreaux Ilene
Bovelsky Christina
Bovelsky Marshall
Bowens Christopher
Boxhill Carlton
Boyle Kevin
Bradley Michael
Brandywine Delaware Sleep Disorder
Brasure Kimberly
Braunfeld Robert
Brennan Kathleen
Brenner Hugh, NP
Bretzius Michelle
Brice Joanne
Britchkow David
Britchkow Michelle
Broady Ronda
Brooks Julius
Brookshire Victoria
brown angela
Brown Elizabeth
Brown Jamie
Brown Sheri
Brownstein Adam
Broyles Melissa
Bryan Joshua
Bryant Deborah
Bryer Joseph
Buckley Charles
Buckley Maureen
Buonocore Allison
Burday Matthew
Burdick Ralph
Burge Taylor
Burnquist Bonnie
Byck Hal
Cahall Tammy
Callahan David
Callahan Robert
Callard Jennifer
Campbell Corder
Campo Darrin
Cancino Josefina
Cantor Ira
Capiro Jose
Capone George
Capuano-Olson Lisa
Cardwell Cassandra
Carney Kevin
Carrigan Estella
Carroccia Robert
Carroll Angela
Carter Raymond
Carunchio Michael
Casale Jessica
Case Charles
Case Mark
Casella Teresa
Castro Jose
Castro Marcia
Caswell Anne
Caswell Monack Brian
Caswell-Monack Brian
Celluci John
Cemerlic Senad
Centers Nathan
Cer Diana
Chambers Carolyn
Chambers Susan
Chan Gina
chandhok sheetal
Chandra Avinash
Chang Deguzman Helen
CHANG FRANCES
Chasanov Caryn
Chasanov William
Chasanov William, III
Chasanov, III William
Chatterjee Geetanjali
Chaudhary Mona
Chaughule Ashlesha
Chehrenama Mahan
Chennadi Sandeep
Cherian Jacob
Chervenak Douglas
Chidekel Aaron
Childers Maria
Childress Caitlin
Chirra Supraja
CHUDZIK SUSAN
Ciarlo Alphonso
Ciganek Eric
Cinderella Joseph
Claravall Odilon
Clark Regina
Clarkson Peta
Clay Anthony
Cohan Teresa
Cohen Valerie
Coker Joan
Colburn Arthur
Collazo Andrea
Collazo d
Collins Audrey
Collins Donald
Collins Scott
Colucci Philomena
Conaty Buck Susan
Connolly Christopher
Connolly Kieran
Connor Mary Ann
Constantini Peter
Conti Marisa
Cooper Amanda
Cooper Stephen
Copeland Kevin
Corcoran Kathleen
Cordova Francis
Corey Donald
Corrigan-Massey Margaret
Countess Jacqueline
Covell William
Cowdery Susan
Coyne B
Cramer Jeffrey
Cristol Jeremy
Crocket - Brasure Kimberly
Crone Tracie
Cross-Skinner Susan
Crouch Michael
Crowe Katy
Culp Jenna
Cummings William
Curci Anthony
Cutler Naomi
Cyriac Chackumkal
D'Amour James
Da Silva Annette
Daghir John
Dahr George
Daliva Agnes
Daly Elizabteh
Daly John
Dammert Coronado Pedro
Damouni Fadi
Danai Pajman
Daniel Ericka
Daniels Maurice
Dante Lee
Das Babulal
Dash Paul
Dassel Jeffrey
Dave Jay
Davies ToriAnne
Davis Alon
Davis Brown Angela
Davis Christopher
Davis Dustin
Davis Eileen
Davis George
Davis Karen
davis krista
Davis Lindsey
Davis Marcus
Davis Rhonda
Davis-Brown Angela
Davis-Williams Angelique
Davison Jean
Day Katherine
Day Robert
De jesus Victorino
De Sanctis Armand
Dean Linda
Debrady Akili
DeCarli John
DeCouto Sammantha
DeCuoto Sammantha
Dedhia Lax
Dees Eric
Deitchman Andrew
DeJoseph Maria
Delaney Debra
Delboy Frederick
Deliri Hamid
Delisser Horace
Deluca Catherine
Demarco Kenneth
Demczko Matthew
Denenberg Barry
Denis Tavani
Denitzio Robert
Denney Emily
Dennis Lee
Deo Shivdeep
DePace Nicholas
Deputy Lyron
Desai Priyal
Desanctis A Neal
Deshmukh Prium
Destefano Louis
Deustch Joseph
dfad afd
Dhamdhere Meghana
Dharia Tejal
Di Marco Anthony
Diamante Theodhor
Diamond Mary
Diamond Steven
Diamond William, Jr
Diaz Gloria
Diaz-Stanchi Maria
Dibal Mbwidiffu
Dickey Tisha
DiDonato Edda
Diefenbeck Cynthia
Diehl Kristine
Diem Ronnie
Diener Steven
Dimarco Claude
DiSabatino Diane
DiSalvo Carmelo
Disibio Robert
Ditty Douglas
Divatia Himani
Divino Lorina
Dixit-Patel Priyanka
Doble Emily
Dolinay Christy
Dombroski Tina
Dominick Ann
Donahue David
Donahue-Smith Catherine
Donlick Robert
Donnelly John
Donnelly Steven
Donohue Andrew
Donohue David
Donohue Dawn
Donohue Leslie
Donohue Zarek
Doorey Andrew
Dopler Bruce
Douglas Ditty
Douglas Lauren
Dowlatshahi Samaneh
Dowling Sally
Dowling Timothy
Downey Timothy
Downing kyra
Doyle Ashley
Drake Andrea
Dressel Kathleen
Dresser Lee
Driban David
Drinkwater Aaryn
Dryer Marylou
Duffalo Lynnae
Duggan Stephen
Duncan Beth
Dunn Thomas
Duran Daniel
Dusak Jill
Duzy Michael
Eakin Jennifer
Eberly David
Eberts Paul
Edelsohn Lanny
Edmondson G Mitchell
Edmondson Loretta
Ednie Andrew
Edwards Tiffany
EEG Delaware Sleep Disorders
Eisner Gilbert
El Sabbagh Firas
El-Amraoui Kathryn
Elder Justin
Eldridge Justin
Elener Valerie
Eliasson Orn
Elkin Rodney
Elliott Daniel
Elmedkhar Mhaidi
Eltgroth Stefan
Eng Jerald
Epelboim-Feldman Joyce
Epstein David
Erlich Rodrigo
Esham Charles
Estes Tracy
Estock David
Evangelista Mark
Evangelista Odette
Ewen Edward
Fabens Elizabeth
Facciolo Gina
Fagan Heather
Fagel Jennifer
Failaev Erin
Falchek Stephen
Falco Frank
Falcone Rita
Fallorina Marita
Fallouh Mohanad
Fanto Kelly Anne
Farooqui Ghazala
Farrell-Armstrong David
Fay Bruce
Fayock Kristopher
Federline Jason
Feeney John
Feinberg Joshua
Feinberg Stanford
Fellows Matthew
Felzer Stuart
Fenice John
Ferenz Susan
Fernandez Liza
Fierro James
Filip Anna
Fink Albert
Fink John
Fiori Dana
Fischer Matthew
Fischer Richard
Fischer Steven
Fisher Daniel
Fisher Nicole
Fisher Todd
Fisher-Jones Beth
Fletcher Alfred
Fletcher Erin
Foley David
Fong Gloria
Foote Sandra
Ford Allison
Ford E
Ford Paul
Ford Russell
Forgione Linda
Fox Kenneth
Fox Stacey
Foy Lauren
Francomano Clair
Franczyk Darren
Freih Mouhanad
Frey Anthony
Frey Jennifer, NP
Frick Kelly
Friedland Allen
Fritzges Katelyn
Fryberger Kelsey
Fucci Pasquale
Funk William
Fuqua Kelly
Furey Anthony
Fynn Theodora
Gabriel Timoteo
Gabrielli Eileen
Gaines David
Gala Nihar
Galib Emile
Gallagher Kimberly
Galloway Amanda
Garcia Maribel
Gardiner Sherry
Gasperi Simone
Gavis Jan
Gaynor Beatrice
Gazze McIlroy Rebecca
Gehring David
Geimeier William
Gellock Jamie
GEORGE NYASHA
Georgetown Delaware Sleep Disorders
Geracimos Eva
Gerald Meis
Gersh Douglas
Ghafoor Sidra
Ghiorzi Thomas
giacalone anna
Gibble Karen
Giddins Danielle
Gideon Nancy
Gigliotti David
Gilani M Javed
Giles Christopher
Gill James
Giminaro Vincent
Gitlin Paul
Glassner Mark
Gleasner Eileen
Gliebus Gediminas
Gluckman Jerry
Go Warren
Godfrey Eugene
Godman Stacey
Goel Annuradha
Gohel Pravinchandra
Goldberg Paul
Goldenberg Edward
Goldstein Gregg
Good Jason Jonathan
Good Michelle
Goodman Ronald
Gopez Carlo
Gordon Pamela Kurz
Gordon Richard
Gorra Jona
Gorrin Paul
Gough Ryan
Goulet Michael
Gourkanti Rao
Govatos Jane
Gover Alina
Goyanes Alice
Grabert Derek
Graboyes Leopold Nancy
Graham Ashley
Grant - McAuley Adelle
Graves Stacey
Gray Samantha
Graziani Corina
Green Aaron
Greenwood Beth
Gregge Brandi
Gregory Ryeneysa
Grewal Harjinder
Griffin Kristine
Griffin-Walls Lauren
Grilli Jennifer
Grinnen Kathryn
Grobman Marc
Groll Jerome
Gross Michael
Grossinger Bruce
Grossman Tina
Grove Cara
Grubbs David
Guarino Jeffrey
Gudipaty Lalitha
Guernsey Louis
Guillard Paul
Gulab Bobby
Gunasekaran Madhumathi
Gupta Monika
Gupta Preet
Gupta Rohit
Gustafson Kathleen
Gutierrez Heydi
Guy Carole
Gwozdz Paul
Haack Hilary
Haas Andrew
Hack David
Haegele Mark
Hafer-Macko Charlene
Hagee Mary
Haines Carolyn
Halbert Caitlin
Haldar Maria
Hale Amy
Hale J
Hale John
Halpern Eric
Hammer Scott
Hamming Barbara
Hammond Jessica
Hancock Alyssa
Hann-Deschaine Jason
Hannan Paul
Hansby Keyma
Hanson Shaun
Haque Mahmudul
Hardt Burchard Jennifer
Hari Hall Kalpana
Harry Lehman
Hart Stephanie
Hasan Nazia
Haug Richard Patrick
Hawk Nicole
Hawtof Jeffrey
Hayes Donald
Hazlett - OBrien Colleen
Heckert Jeffrey
Hefner-Erickson Kathe
Heinle Robert
Heldt Cynthia
Heller Marc
Helou Beshara
Hendley Yolanda
Hendricks Johnita
Hendrie Donna
Hennessy Timothy
Hernandez Brianne
Hernandez Jenaro
Hewes Hannah
Hickman Heather
Hiester Melanie
High Mary
Hill Ashley
Hill Charles
Hilton Thomas
Hitchens Amy
Hitchens Donna
Hockstein Neil
Hocutt John
Hodgson Paul
Hoffman David
Hoffman Deborah
Hoffman Veronica
Hogan Elise
Hohl Lisa
Holdinsky Stacie
Hollis Brett
Holmes Gregory
Homas Nancy
Hooker Maryann
Hopkins James
Hopple Alice
Horah Christine
Horan Dennis
Horn Brian
Horn Robin
Horseman Mary
Horstmyer James
Horton Terry
Hosmane Vinay
Hosny Maged
Hough Cristina
Howard Nicole
Howard Paul
Howett Judy
Howett Sherin
Hsu Juichih
Hubbs James
Hudson Sheria
Hughes Jenny
Hunt Clifton
Hunter Kevin
Hurd Jennifer
Husain-Krautter Sehba
Hussain Zainal
Hussain Zehra
Hutchinson, III Harry
Ianni Carolyn
Ibrahim George
Ibrahim Howett Sherin
Ice Melanie
Ifechukwude Nneamaka
Ikomi Jolomi
Ilustre Joanne
Imber Paul
Ingram Annie
Inguito, Jr. Galicano
INSPIRE INSPIRE
Irelan Lori
Irgau Isaias
Isaac Susan
Ishwar Aradhana
Isiocha Henry
Islam Malick
Ismail Hummayun
Ivins Seth
Izzo Philip
Jacinto Raymond
Jackel Roy
Jackovic Elizabeth
Jackson Abbe
Jackson Cheryl
Jackson Kristine
Jacob Patricia
Jacobson Matthew
Jaffe Rebecca
Jamali Farhad
James Phyllis
Jani Uday
Janney Brian
Jansen Tracy
Jaradat Lara
Jarrell T. Noble
Jarrell Twifford
Jawahar David
Jeha Zeina
Jezyk David
John Melissa
Johnson Abbey
Johnson Penny
Johnson Shirline
Jones Beth
Jones Blair
Jones Horatio
Jones Mark
Jordan Julia
Josey Leeketra
Joshi Madan
Joshi Preet
Joy Sarah
Judd Sylvia
Judy Stephanie
Junfang Jiao
Kabir Arif
Kahlon Sandeep
Kahn Fred
Kalodner David
Kamara Margaret
Kamat Manisha
Kamen Jonathan
Kamran Tareen
Kantor Lawrence
Karalis Helen
Karen McGibbon
Karnish Joseph
Kass Erik
Kathryn Wagner
Katz Faca Paul
Kauta Shilpa
Kavanaugh Erin
Kaza Janaki
Kehagias Ioannis
Kehagias John
Kelleher Michael
Kelley Daniel
Kelly Bonnie
Kelly III John
Kelly Karen
Kelly Thomas
Kemp Lawrence
Kendema Tabe
Kenia Anand
Kenkre Poorwa
Kennedy Michael
KERKULA LEEMU
Kerstetter Megan
Kerzner Roger
Keshishyan Sevak
Khan Azhar
Khan Mohammad
Khan Omar
Khan Shahnawaz
Khandelwal Rashmi
Kight Matthew
Kim Christopher
Kim Eun
Kim Joseph
Kim Sofia
Kim Yuli
King Bernard
King Laura
King Matthew
Kinkel Karen
Kirchdoeffer Susan
Kirchdoerffer Susan
Kirk Deborah
Klair Stephanie
Klinefelter Lelsie
Knaub Marilyn
Knox, Jr James
Kobak Mary
Koch Jason
Kofahi Raid
Kohl David
Kohli-Werner Heather
Konstantopoulis Lefteria
Kontra Ashley
Kopecki Robert
Kossidas Konstantinos
Kostal Michael
Kotak Kanchan
Koterwas Matthew John
Kousoulis Georgia
Krafchick Michael
Kraman-Roach Lillian
Kramer Hal
Krasner David
Kreider Mary Elizabeth
Krider Wayne
Kripalu Chetana
Kripalu Vinod
Kuczmarski Michael
Kuhnen Ann
Kumar Ajith
Kumar Sambhab
Kuon Thomas
Kurzrok Scott
Kus Michelle
Kushner Stephen
Kwan Delbert
Kwon Grace
Labin Charles
Lahey Imelyn
Lahman Mandi
Laje Gonzalo
Lammly Adam
Lamond Katherine
Lande Leah
Lander Kenneth
Landis Mark
Landrum Kimberly
Langan Timothy
Lasson Nancy
Latona Lori
Lattin Neil
Lauren Foy
Lavin Erin
Lawrence John
Lazar Maria
LE HUY
Leach Kathleen
Lecomte Jennifer
Lee Gene
Lee Harvey
Lee Wai
Leidig Gilbert
Leon Samuel
Leonard David
Leonardi Cheryl
Leschek-Gelman Lisa
LESSER RAYMOND
Leung Doris
Levin Victoria
Levine Monica
Levy Mark
Lewis Ronald
Li Ina
Lim Judy
Limberakis Jaclyn
Limpert George
LINCOLN JENNIFER
Lippmann Michael
Lipson Susan
Little Theresa
Lobo Vincent
Lopez Diaz Tamara
lopez kelly
Lopez Kelly Anne
Lotkowski James
Lotkowski Jason
Loughlin-Pherribo Donna
Loughran James
Loughran Joseph
Lourie Stacy
Lowe Cynthia
Lowe Gillian
Ludwicki John
Luft Jay
Luna Ronald
Lupone marie
Lust James
Lynn Morgan
Macgill Alice
Mackey Jill
Macko Erin
Macks Erin
Madarang Melchor
Magat Anna
Magat Karlo
Magat Lakan Karlo
Magaziner Allan
Maged David
Magtagnob Efrem
Maharjan Raju
Makonnen Eyob
Malaro Margaret
Malebranche Lionel
Maleh David
Malleus Stephanie
Mallozzi Mariano
Maloney Michael
Manfield Laura
Mann Sandeep
Mansoor Maryah
Maranzini Paul
Marcalus Eric
Marcotte Gregory
Marcus Avron
Marcus Roger
Marefat Armin
Marhefka Gregary
Mark Michael
Markland Darra
Markman Lawrence
Markov Dimitri
Marmo Vincent
Marquez Misael
Marr Amanda
Marriner Jennifer
Marshall Erik
Martin Heather
Martin Michael
Martinez Axel
Martini David
Martz Rebecca Lynn
Maru Poonam
Marvel Joann
Marvin Andrea
Marymor Neil
Masciantonio Ann
Maser Beverly
Maslen Thomas
Masri Bassem
Mathew Mini
Matis Clare
Matthews Andrea
Matz Paul
Mawn Victoria
Maxwell Lisa
Maya Hector
Mazel Jay Aaron
Mazur Todd
Mazzola Christine
McAuley Valerie
McCarter Matthew
McClure Jennifer
McConnell Lila
Mccullough Daniel
McDonnaugh- Washam Stephanie
McDonnell Patricia
Mcdonough Renee
McGhee Karen
McGibbon Karen
Mcgill Kathy
Mcglaughlin-Frick Kelly
McIntosh Karl
McIntosh Shauna
Mclaughlin Raymond
Meadows Rita
Meckelnburg Robert
Medford William
Mehta Gaurav
Mehta Shilpa
Melendez Mayda
Menaldino Stephen
Menard Joshua
Mentle Iris
Merlo Francis
Merrick Helen
Merritt Neasha
Mertens Avalon Corinne
Metzger M Diana
Meyer Christine
Meyerson Scott
Michalak Jean Marie
Michel Kaysha
Micklin Alan
Middletown Delaware Sleep Disorder
Mikkilineni Rao
Miller Good Michelle
Miller Raymond
Miller Tiwana
Milligan Jack
Mills Bethanne
Mitra Bipasha
Mochache Soire Ellen
Mochache-Soire Ellen
Moles James
Molony Regina
Monaco Carolyn
Monnig Melanie
Monteleone Robert
Montigney Paul
Montone Francis
Montoya Monica
Montross-Lopez Elisa
Moore Ann
MOORE ARIEL GIBSON
Moore Jane
Moore Joan
Moosavy Farid
Morales Patricia
Morgan Gouveia Melissa
Morgan Mark
Morren John
Morris Michelle
Morris-Taylor Carla
Morrison Naikeya
Morthole Frances
Mostafa Ashraf
Mousaw Christie
Moutsatsos Alexia
Moutsatsos George
Much Mandell
Mukherjee Ratnakar
Mullin Miriam
Mullins Sarah
Mulvey John
Mumm Eileen
Munda Patricia
Murphy Bowens Noreen
Murray Kathleen
Myers Andrew
Myers Christopher
Myers G Robert
Myers Ian
Nadig Paula
Nagel William Joseph
Nalda Kimberly
Namey George
Narasimaiah Rajshekar
Nardozzi Brenda
Narewski Erin
Narun Lawrence
Nash Andrew
Nashed Maher
Nashed Suzy
Navarro Julio
Neef Thomas
Neiberg Marc
Newark Delaware Sleep Disorders
Newswanger Dana
Ng Manyan
Nguyen Hang
Nguyen Kim - Huong
NiCastro Oswaldo
Nicholson Cheryl
Nigro Cynthia
Noble Lori
Nolt Curtis
Nottingham William
O Brien Matthew
O'Donnell Linsey
O'Donnell Timothy
O'Hara Kevin
O'Kane Jacqueline
O'Neill John
Obeidy Mujib
Obenshain Wallace
Ocampo-Lim Blanca
Odonnell Timothy
Ogden Stephen
Ogunwande Clement
Okane Jacqueline
Okeefe Kevin
Olekszyk Joseph
Oliphant Kimberley
Olivere Linda
Olivieri Robert
Olson kate
Oroszlan Peter
Osei-Afriye Jennifer
Ostrea Francis
Owens Anjali
Padman Raj
Pahwa Anjala
Palaker Bhaskar
Palandjian Robert
Palekar Bhaskar
Palermo Sonia
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Palmer Josette
Pando Jose
Panettieri Reynold
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Paoli Matthew
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Parks Susan
Pastore Gaetano
Patel Nilam
Patel Rajesh
Patel Sanjeev
Patel Visha
Patel Vishal
Paul Richard
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Pelimskaya Lutsiya
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Pena Ivan
Pennington Iii Joseph
Penny Stephen
Pepe Teresa
Perella Anthony
Perez Pedro
Peric Stepcic Gordana
Perkis Renee
Peters Kelli
Peters Michael
Peterson Do Joshua
Pezzuto Tara
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Phillips Kyle
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Pierce Gregory
Pierskalla Ronald
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Pocinki Alan
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Porter Amanda
Porter Laurie
Potter Alison
Powell John
Prasad Rajinder
Pratt Tamela
Prattipati Madhu
Prettyman Allen
Prigg Brian
Prosseda Julie
Pula Narayana
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Pulchny Paul
Purcell Patricia
Puri Vineet
Py Kieran
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Quercetti Kelli Ann
Quigley Craig
Quirk Brian
Qureshi Ehtasham
Qureshi Wasif
Radewonuk Lyndsay
Raff Heather
Raffaele Melissa
Raffel Gary
Raghuwanshi Anita
Raguraj Sinnarajah
Ramsaran Vince
Ransehousen Suzanne
Rapacciuolo Jamie
Rappaport Brandi
Rastogi Ritu
Ratner Richard
Ray Sean
Razon Rhea Victoria
Razvi Mukarram
Rebmann Valerie
Reddy Roopika
Rees John
Reetz Matthew
Rehoboth Delaware Sleep Disorder
Reid Lisa
Reinhardt John
Renzulli Beth
Renzulli Elizabeth
Reyes Carlos
Reyes David
Reynolds Candice
Reynolds, FNP Marcia
Rhoads Martinez Rita
Ricci John
Richman Edward
Ricker Melinda
Rippert Judith
Risser Andreya
Rizk Salim
Rizzo Albert
Roach Macey
Roach Zachary
Robert Denitzio
Roberts Bonnie
Roberts Candice
Roberts Tracie
Robertson Joanna
Robino Donna
Robino Donna Marie
Robinson Amy
Robinson Lindsay
Robinson Ryan
Robson Bryanne
Rodgers Thomas
Rodkey James
Rogers Jennifer
Rolfes Robert
Rollins Julie
Romak Jonathan
Ronis Max
Roofeh David
Rosa Ramon
Rosal Rufino
Rosell Wilfredo
Rosen Michael
Ross Warren
Rosselli John
Rossi Beth
Rossi Lisa
ROTHROCK ROBERT
Rowen Kathlyn
Rowles John
Rubacky Joseph
Ruckdeschel Emily
Rudenstein Robert
Rudnick Adam
Russ Courtney
Russ Friedman Courtney
Rutledge Paula
Ryan Nicole
Saberi Mansour
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Sachdev Sheelmohan
Sachedeva Ashutosh
Saldarriaga Angela
Sallee Kent
Samaha Michel
Sandal Candace
Sandrian Molly
Sanwal Pankaj
Saravanan Ana
Sardi-Freitez Alejandro
Sargent Keith
Sarter Brian
Satriale Robert
Sayeeduddin Sayed
Scaffidi Roberto
Schaeffer Mark
Schaeffer Scott
Scheid David
Schenck Sarah
Scheper Christine
Schiffman Melissa
Schimpf Valerie
Schmitt Mary Eileen
Schneider Bernard
Schockemoehl Jennifer
Schrandt Neil
Schroyer Helena
Schumacker Clifford
Schwartz Eric
Schwartz Walter
Schwartzman Noah
Schwarz Eric
Schweizer Robert
Scott Lowell
Scott Nicole
Sehbai Aasim
Sehgal Manu
Seiff Jenna
Semanchik Holly
Sender Greg
Senuoke Oluseyi
Septer Michelle
Seretis George
Sergott Robert
Sevitski David
Shade Jennifer
Shah Udayan
Shahzad Farnaz
Shaikh Mushtaq
Shao Leon
Shapiro Tiffany
Sharbaugh Charles
Sharma Madhuri
Sharman Daryl
Sharon Idan
Shea Michael
Sheahan Kevin
Sheehan Lori
Sheehan Melissa
Sheppard William
Sheridan Martin
Shertel Victoria
Shilpa Kauta
Shimoura Steven
Shin Ju Young
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Sidari Jude
Siddiqui Masood
Silversteen Jason
Silverstein Julie
Simpson David
Simpson Robin
Singh Gurmeet
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Sipala Elizabeth
Sivieri Mark
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Slack Melanie
Slobogin Gina
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Smalley Kristina
Smith Bruce
Smith Curtis
Smith Kenneth
Smith Kerri Akaya
Smith Rachel
Smith Renee
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Smyrna Delaware Sleep Disorder
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Socha Barbara
Sofronski Michael
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Sokoloff Keith
Sollie Lynn
Solomon Lawrence
Soma Parvathi
Somasundaram Parvathi
Somasundarum Parvathi
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Sordi Mark
Sorouri Bijan
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Spiegel Joseph
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Springside Delaware Sleep Disorder
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Stanislav Charles
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Stankiewicz Jason
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Stewart David
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Syravanh Chanhsamona
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Tan Theodore
Tanchanco Rodrigo Cordero
Tapino Erika Lawson
Tarburton Alyssa
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Taylor Steven
Tee Andrew
Teitelbaum Jacob
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Tejeira Ruben
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Townsend Suzanne
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Umosella Charles
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Valencia Carlo
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Vasile Anthony
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Weiner Henry
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Afilaka Olasumbo
Afzal Mohammed
Agard Reynold
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Borodulia Nicholas
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Boudreaux Ilene
Bovelsky Christina
Bovelsky Marshall
Bowens Christopher
Boxhill Carlton
Boyle Kevin
Bradley Michael
Brandywine Delaware Sleep Disorder
Brasure Kimberly
Braunfeld Robert
Brennan Kathleen
Brenner Hugh, NP
Bretzius Michelle
Brice Joanne
Britchkow David
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Broady Ronda
Brooks Julius
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brown angela
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Brown Jamie
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Carroccia Robert
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Case Mark
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Castro Jose
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Caswell Monack Brian
Caswell-Monack Brian
Celluci John
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Chambers Susan
Chan Gina
chandhok sheetal
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Chasanov Caryn
Chasanov William
Chasanov William, III
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Chatterjee Geetanjali
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Cherian Jacob
Chervenak Douglas
Chidekel Aaron
Childers Maria
Childress Caitlin
Chirra Supraja
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Cinderella Joseph
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Clark Regina
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Clay Anthony
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Coker Joan
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Collazo Andrea
Collazo d
Collins Audrey
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Colucci Philomena
Conaty Buck Susan
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Connolly Kieran
Connor Mary Ann
Constantini Peter
Conti Marisa
Cooper Amanda
Cooper Stephen
Copeland Kevin
Corcoran Kathleen
Cordova Francis
Corey Donald
Corrigan-Massey Margaret
Countess Jacqueline
Covell William
Cowdery Susan
Coyne B
Cramer Jeffrey
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Crocket - Brasure Kimberly
Crone Tracie
Cross-Skinner Susan
Crouch Michael
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Culp Jenna
Cummings William
Curci Anthony
Cutler Naomi
Cyriac Chackumkal
D'Amour James
Da Silva Annette
Daghir John
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Daly John
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Damouni Fadi
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Dash Paul
Dassel Jeffrey
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Davis Alon
Davis Brown Angela
Davis Christopher
Davis Dustin
Davis Eileen
Davis George
Davis Karen
davis krista
Davis Lindsey
Davis Marcus
Davis Rhonda
Davis-Brown Angela
Davis-Williams Angelique
Davison Jean
Day Katherine
Day Robert
De jesus Victorino
De Sanctis Armand
Dean Linda
Debrady Akili
DeCarli John
DeCouto Sammantha
DeCuoto Sammantha
Dedhia Lax
Dees Eric
Deitchman Andrew
DeJoseph Maria
Delaney Debra
Delboy Frederick
Deliri Hamid
Delisser Horace
Deluca Catherine
Demarco Kenneth
Demczko Matthew
Denenberg Barry
Denis Tavani
Denitzio Robert
Denney Emily
Dennis Lee
Deo Shivdeep
DePace Nicholas
Deputy Lyron
Desai Priyal
Desanctis A Neal
Deshmukh Prium
Destefano Louis
Deustch Joseph
dfad afd
Dhamdhere Meghana
Dharia Tejal
Di Marco Anthony
Diamante Theodhor
Diamond Mary
Diamond Steven
Diamond William, Jr
Diaz Gloria
Diaz-Stanchi Maria
Dibal Mbwidiffu
Dickey Tisha
DiDonato Edda
Diefenbeck Cynthia
Diehl Kristine
Diem Ronnie
Diener Steven
Dimarco Claude
DiSabatino Diane
DiSalvo Carmelo
Disibio Robert
Ditty Douglas
Divatia Himani
Divino Lorina
Dixit-Patel Priyanka
Doble Emily
Dolinay Christy
Dombroski Tina
Dominick Ann
Donahue David
Donahue-Smith Catherine
Donlick Robert
Donnelly John
Donnelly Steven
Donohue Andrew
Donohue David
Donohue Dawn
Donohue Leslie
Donohue Zarek
Doorey Andrew
Dopler Bruce
Douglas Ditty
Douglas Lauren
Dowlatshahi Samaneh
Dowling Sally
Dowling Timothy
Downey Timothy
Downing kyra
Doyle Ashley
Drake Andrea
Dressel Kathleen
Dresser Lee
Driban David
Drinkwater Aaryn
Dryer Marylou
Duffalo Lynnae
Duggan Stephen
Duncan Beth
Dunn Thomas
Duran Daniel
Dusak Jill
Duzy Michael
Eakin Jennifer
Eberly David
Eberts Paul
Edelsohn Lanny
Edmondson G Mitchell
Edmondson Loretta
Ednie Andrew
Edwards Tiffany
EEG Delaware Sleep Disorders
Eisner Gilbert
El Sabbagh Firas
El-Amraoui Kathryn
Elder Justin
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Elener Valerie
Eliasson Orn
Elkin Rodney
Elliott Daniel
Elmedkhar Mhaidi
Eltgroth Stefan
Eng Jerald
Epelboim-Feldman Joyce
Epstein David
Erlich Rodrigo
Esham Charles
Estes Tracy
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Evangelista Mark
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Ewen Edward
Fabens Elizabeth
Facciolo Gina
Fagan Heather
Fagel Jennifer
Failaev Erin
Falchek Stephen
Falco Frank
Falcone Rita
Fallorina Marita
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Farooqui Ghazala
Farrell-Armstrong David
Fay Bruce
Fayock Kristopher
Federline Jason
Feeney John
Feinberg Joshua
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Fellows Matthew
Felzer Stuart
Fenice John
Ferenz Susan
Fernandez Liza
Fierro James
Filip Anna
Fink Albert
Fink John
Fiori Dana
Fischer Matthew
Fischer Richard
Fischer Steven
Fisher Daniel
Fisher Nicole
Fisher Todd
Fisher-Jones Beth
Fletcher Alfred
Fletcher Erin
Foley David
Fong Gloria
Foote Sandra
Ford Allison
Ford E
Ford Paul
Ford Russell
Forgione Linda
Fox Kenneth
Fox Stacey
Foy Lauren
Francomano Clair
Franczyk Darren
Freih Mouhanad
Frey Anthony
Frey Jennifer, NP
Frick Kelly
Friedland Allen
Fritzges Katelyn
Fryberger Kelsey
Fucci Pasquale
Funk William
Fuqua Kelly
Furey Anthony
Fynn Theodora
Gabriel Timoteo
Gabrielli Eileen
Gaines David
Gala Nihar
Galib Emile
Gallagher Kimberly
Galloway Amanda
Garcia Maribel
Gardiner Sherry
Gasperi Simone
Gavis Jan
Gaynor Beatrice
Gazze McIlroy Rebecca
Gehring David
Geimeier William
Gellock Jamie
GEORGE NYASHA
Georgetown Delaware Sleep Disorders
Geracimos Eva
Gerald Meis
Gersh Douglas
Ghafoor Sidra
Ghiorzi Thomas
giacalone anna
Gibble Karen
Giddins Danielle
Gideon Nancy
Gigliotti David
Gilani M Javed
Giles Christopher
Gill James
Giminaro Vincent
Gitlin Paul
Glassner Mark
Gleasner Eileen
Gliebus Gediminas
Gluckman Jerry
Go Warren
Godfrey Eugene
Godman Stacey
Goel Annuradha
Gohel Pravinchandra
Goldberg Paul
Goldenberg Edward
Goldstein Gregg
Good Jason Jonathan
Good Michelle
Goodman Ronald
Gopez Carlo
Gordon Pamela Kurz
Gordon Richard
Gorra Jona
Gorrin Paul
Gough Ryan
Goulet Michael
Gourkanti Rao
Govatos Jane
Gover Alina
Goyanes Alice
Grabert Derek
Graboyes Leopold Nancy
Graham Ashley
Grant - McAuley Adelle
Graves Stacey
Gray Samantha
Graziani Corina
Green Aaron
Greenwood Beth
Gregge Brandi
Gregory Ryeneysa
Grewal Harjinder
Griffin Kristine
Griffin-Walls Lauren
Grilli Jennifer
Grinnen Kathryn
Grobman Marc
Groll Jerome
Gross Michael
Grossinger Bruce
Grossman Tina
Grove Cara
Grubbs David
Guarino Jeffrey
Gudipaty Lalitha
Guernsey Louis
Guillard Paul
Gulab Bobby
Gunasekaran Madhumathi
Gupta Monika
Gupta Preet
Gupta Rohit
Gustafson Kathleen
Gutierrez Heydi
Guy Carole
Gwozdz Paul
Haack Hilary
Haas Andrew
Hack David
Haegele Mark
Hafer-Macko Charlene
Hagee Mary
Haines Carolyn
Halbert Caitlin
Haldar Maria
Hale Amy
Hale J
Hale John
Halpern Eric
Hammer Scott
Hamming Barbara
Hammond Jessica
Hancock Alyssa
Hann-Deschaine Jason
Hannan Paul
Hansby Keyma
Hanson Shaun
Haque Mahmudul
Hardt Burchard Jennifer
Hari Hall Kalpana
Harry Lehman
Hart Stephanie
Hasan Nazia
Haug Richard Patrick
Hawk Nicole
Hawtof Jeffrey
Hayes Donald
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Heckert Jeffrey
Hefner-Erickson Kathe
Heinle Robert
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Helou Beshara
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Hendricks Johnita
Hendrie Donna
Hennessy Timothy
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Hill Charles
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Hoffman Deborah
Hoffman Veronica
Hogan Elise
Hohl Lisa
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Homas Nancy
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Hopkins James
Hopple Alice
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Horan Dennis
Horn Brian
Horn Robin
Horseman Mary
Horstmyer James
Horton Terry
Hosmane Vinay
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Howard Nicole
Howard Paul
Howett Judy
Howett Sherin
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Hubbs James
Hudson Sheria
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Hunter Kevin
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Ianni Carolyn
Ibrahim George
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Ifechukwude Nneamaka
Ikomi Jolomi
Ilustre Joanne
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Jacinto Raymond
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Jacob Patricia
Jacobson Matthew
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Jamali Farhad
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Jansen Tracy
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Jeha Zeina
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Jones Beth
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Jones Mark
Jordan Julia
Josey Leeketra
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Junfang Jiao
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Kahn Fred
Kalodner David
Kamara Margaret
Kamat Manisha
Kamen Jonathan
Kamran Tareen
Kantor Lawrence
Karalis Helen
Karen McGibbon
Karnish Joseph
Kass Erik
Kathryn Wagner
Katz Faca Paul
Kauta Shilpa
Kavanaugh Erin
Kaza Janaki
Kehagias Ioannis
Kehagias John
Kelleher Michael
Kelley Daniel
Kelly Bonnie
Kelly III John
Kelly Karen
Kelly Thomas
Kemp Lawrence
Kendema Tabe
Kenia Anand
Kenkre Poorwa
Kennedy Michael
KERKULA LEEMU
Kerstetter Megan
Kerzner Roger
Keshishyan Sevak
Khan Azhar
Khan Mohammad
Khan Omar
Khan Shahnawaz
Khandelwal Rashmi
Kight Matthew
Kim Christopher
Kim Eun
Kim Joseph
Kim Sofia
Kim Yuli
King Bernard
King Laura
King Matthew
Kinkel Karen
Kirchdoeffer Susan
Kirchdoerffer Susan
Kirk Deborah
Klair Stephanie
Klinefelter Lelsie
Knaub Marilyn
Knox, Jr James
Kobak Mary
Koch Jason
Kofahi Raid
Kohl David
Kohli-Werner Heather
Konstantopoulis Lefteria
Kontra Ashley
Kopecki Robert
Kossidas Konstantinos
Kostal Michael
Kotak Kanchan
Koterwas Matthew John
Kousoulis Georgia
Krafchick Michael
Kraman-Roach Lillian
Kramer Hal
Krasner David
Kreider Mary Elizabeth
Krider Wayne
Kripalu Chetana
Kripalu Vinod
Kuczmarski Michael
Kuhnen Ann
Kumar Ajith
Kumar Sambhab
Kuon Thomas
Kurzrok Scott
Kus Michelle
Kushner Stephen
Kwan Delbert
Kwon Grace
Labin Charles
Lahey Imelyn
Lahman Mandi
Laje Gonzalo
Lammly Adam
Lamond Katherine
Lande Leah
Lander Kenneth
Landis Mark
Landrum Kimberly
Langan Timothy
Lasson Nancy
Latona Lori
Lattin Neil
Lauren Foy
Lavin Erin
Lawrence John
Lazar Maria
LE HUY
Leach Kathleen
Lecomte Jennifer
Lee Gene
Lee Harvey
Lee Wai
Leidig Gilbert
Leon Samuel
Leonard David
Leonardi Cheryl
Leschek-Gelman Lisa
LESSER RAYMOND
Leung Doris
Levin Victoria
Levine Monica
Levy Mark
Lewis Ronald
Li Ina
Lim Judy
Limberakis Jaclyn
Limpert George
LINCOLN JENNIFER
Lippmann Michael
Lipson Susan
Little Theresa
Lobo Vincent
Lopez Diaz Tamara
lopez kelly
Lopez Kelly Anne
Lotkowski James
Lotkowski Jason
Loughlin-Pherribo Donna
Loughran James
Loughran Joseph
Lourie Stacy
Lowe Cynthia
Lowe Gillian
Ludwicki John
Luft Jay
Luna Ronald
Lupone marie
Lust James
Lynn Morgan
Macgill Alice
Mackey Jill
Macko Erin
Macks Erin
Madarang Melchor
Magat Anna
Magat Karlo
Magat Lakan Karlo
Magaziner Allan
Maged David
Magtagnob Efrem
Maharjan Raju
Makonnen Eyob
Malaro Margaret
Malebranche Lionel
Maleh David
Malleus Stephanie
Mallozzi Mariano
Maloney Michael
Manfield Laura
Mann Sandeep
Mansoor Maryah
Maranzini Paul
Marcalus Eric
Marcotte Gregory
Marcus Avron
Marcus Roger
Marefat Armin
Marhefka Gregary
Mark Michael
Markland Darra
Markman Lawrence
Markov Dimitri
Marmo Vincent
Marquez Misael
Marr Amanda
Marriner Jennifer
Marshall Erik
Martin Heather
Martin Michael
Martinez Axel
Martini David
Martz Rebecca Lynn
Maru Poonam
Marvel Joann
Marvin Andrea
Marymor Neil
Masciantonio Ann
Maser Beverly
Maslen Thomas
Masri Bassem
Mathew Mini
Matis Clare
Matthews Andrea
Matz Paul
Mawn Victoria
Maxwell Lisa
Maya Hector
Mazel Jay Aaron
Mazur Todd
Mazzola Christine
McAuley Valerie
McCarter Matthew
McClure Jennifer
McConnell Lila
Mccullough Daniel
McDonnaugh- Washam Stephanie
McDonnell Patricia
Mcdonough Renee
McGhee Karen
McGibbon Karen
Mcgill Kathy
Mcglaughlin-Frick Kelly
McIntosh Karl
McIntosh Shauna
Mclaughlin Raymond
Meadows Rita
Meckelnburg Robert
Medford William
Mehta Gaurav
Mehta Shilpa
Melendez Mayda
Menaldino Stephen
Menard Joshua
Mentle Iris
Merlo Francis
Merrick Helen
Merritt Neasha
Mertens Avalon Corinne
Metzger M Diana
Meyer Christine
Meyerson Scott
Michalak Jean Marie
Michel Kaysha
Micklin Alan
Middletown Delaware Sleep Disorder
Mikkilineni Rao
Miller Good Michelle
Miller Raymond
Miller Tiwana
Milligan Jack
Mills Bethanne
Mitra Bipasha
Mochache Soire Ellen
Mochache-Soire Ellen
Moles James
Molony Regina
Monaco Carolyn
Monnig Melanie
Monteleone Robert
Montigney Paul
Montone Francis
Montoya Monica
Montross-Lopez Elisa
Moore Ann
MOORE ARIEL GIBSON
Moore Jane
Moore Joan
Moosavy Farid
Morales Patricia
Morgan Gouveia Melissa
Morgan Mark
Morren John
Morris Michelle
Morris-Taylor Carla
Morrison Naikeya
Morthole Frances
Mostafa Ashraf
Mousaw Christie
Moutsatsos Alexia
Moutsatsos George
Much Mandell
Mukherjee Ratnakar
Mullin Miriam
Mullins Sarah
Mulvey John
Mumm Eileen
Munda Patricia
Murphy Bowens Noreen
Murray Kathleen
Myers Andrew
Myers Christopher
Myers G Robert
Myers Ian
Nadig Paula
Nagel William Joseph
Nalda Kimberly
Namey George
Narasimaiah Rajshekar
Nardozzi Brenda
Narewski Erin
Narun Lawrence
Nash Andrew
Nashed Maher
Nashed Suzy
Navarro Julio
Neef Thomas
Neiberg Marc
Newark Delaware Sleep Disorders
Newswanger Dana
Ng Manyan
Nguyen Hang
Nguyen Kim - Huong
NiCastro Oswaldo
Nicholson Cheryl
Nigro Cynthia
Noble Lori
Nolt Curtis
Nottingham William
O Brien Matthew
O'Donnell Linsey
O'Donnell Timothy
O'Hara Kevin
O'Kane Jacqueline
O'Neill John
Obeidy Mujib
Obenshain Wallace
Ocampo-Lim Blanca
Odonnell Timothy
Ogden Stephen
Ogunwande Clement
Okane Jacqueline
Okeefe Kevin
Olekszyk Joseph
Oliphant Kimberley
Olivere Linda
Olivieri Robert
Olson kate
Oroszlan Peter
Osei-Afriye Jennifer
Ostrea Francis
Owens Anjali
Padman Raj
Pahwa Anjala
Palaker Bhaskar
Palandjian Robert
Palekar Bhaskar
Palermo Sonia
Palli Vasu
Palmer Fawn
Palmer Josette
Pando Jose
Panettieri Reynold
Panichelli Ashley
Panunto Karen
Paoli Matthew
Papa Gregory
Papa Michelle
Papili Brittany
Parey Barbara
Parikh Ashish
Parikh Mona
Parise Joseph
Parks Kelly
Parks Susan
Pastore Gaetano
Patel Nilam
Patel Rajesh
Patel Sanjeev
Patel Visha
Patel Vishal
Paul Richard
Pearson John
Pecorella, NP Christina
Pelimskaya Lutsiya
Peluso Susan
Pena Ivan
Pennington Iii Joseph
Penny Stephen
Pepe Teresa
Perella Anthony
Perez Pedro
Peric Stepcic Gordana
Perkis Renee
Peters Kelli
Peters Michael
Peterson Do Joshua
Pezzuto Tara
Phillips Kelly
Phillips Kyle
Phillips Mikelle
Phoenix Charla
Pierce Gregory
Pierskalla Ronald
Pirestani Alireza
Pocinki Alan
Pollice Mary
Pollner Phillip
Poore Heidi
Popescu Andra
Porteous Mary Katherine
Porter Amanda
Porter Laurie
Potter Alison
Powell John
Prasad Rajinder
Pratt Tamela
Prattipati Madhu
Prettyman Allen
Prigg Brian
Prosseda Julie
Pula Narayana
Pula Narayana Rao
Pulchny Paul
Purcell Patricia
Puri Vineet
Py Kieran
Pychynski Dagmara Marta
Quercetti Kelli Ann
Quigley Craig
Quirk Brian
Qureshi Ehtasham
Qureshi Wasif
Radewonuk Lyndsay
Raff Heather
Raffaele Melissa
Raffel Gary
Raghuwanshi Anita
Raguraj Sinnarajah
Ramsaran Vince
Ransehousen Suzanne
Rapacciuolo Jamie
Rappaport Brandi
Rastogi Ritu
Ratner Richard
Ray Sean
Razon Rhea Victoria
Razvi Mukarram
Rebmann Valerie
Reddy Roopika
Rees John
Reetz Matthew
Rehoboth Delaware Sleep Disorder
Reid Lisa
Reinhardt John
Renzulli Beth
Renzulli Elizabeth
Reyes Carlos
Reyes David
Reynolds Candice
Reynolds, FNP Marcia
Rhoads Martinez Rita
Ricci John
Richman Edward
Ricker Melinda
Rippert Judith
Risser Andreya
Rizk Salim
Rizzo Albert
Roach Macey
Roach Zachary
Robert Denitzio
Roberts Bonnie
Roberts Candice
Roberts Tracie
Robertson Joanna
Robino Donna
Robino Donna Marie
Robinson Amy
Robinson Lindsay
Robinson Ryan
Robson Bryanne
Rodgers Thomas
Rodkey James
Rogers Jennifer
Rolfes Robert
Rollins Julie
Romak Jonathan
Ronis Max
Roofeh David
Rosa Ramon
Rosal Rufino
Rosell Wilfredo
Rosen Michael
Ross Warren
Rosselli John
Rossi Beth
Rossi Lisa
ROTHROCK ROBERT
Rowen Kathlyn
Rowles John
Rubacky Joseph
Ruckdeschel Emily
Rudenstein Robert
Rudnick Adam
Russ Courtney
Russ Friedman Courtney
Rutledge Paula
Ryan Nicole
Saberi Mansour
Sacharok Cynthia
Sachdev Madhu
Sachdev Sheelmohan
Sachedeva Ashutosh
Saldarriaga Angela
Sallee Kent
Samaha Michel
Sandal Candace
Sandrian Molly
Sanwal Pankaj
Saravanan Ana
Sardi-Freitez Alejandro
Sargent Keith
Sarter Brian
Satriale Robert
Sayeeduddin Sayed
Scaffidi Roberto
Schaeffer Mark
Schaeffer Scott
Scheid David
Schenck Sarah
Scheper Christine
Schiffman Melissa
Schimpf Valerie
Schmitt Mary Eileen
Schneider Bernard
Schockemoehl Jennifer
Schrandt Neil
Schroyer Helena
Schumacker Clifford
Schwartz Eric
Schwartz Walter
Schwartzman Noah
Schwarz Eric
Schweizer Robert
Scott Lowell
Scott Nicole
Sehbai Aasim
Sehgal Manu
Seiff Jenna
Semanchik Holly
Sender Greg
Senuoke Oluseyi
Septer Michelle
Seretis George
Sergott Robert
Sevitski David
Shade Jennifer
Shah Udayan
Shahzad Farnaz
Shaikh Mushtaq
Shao Leon
Shapiro Tiffany
Sharbaugh Charles
Sharma Madhuri
Sharman Daryl
Sharon Idan
Shea Michael
Sheahan Kevin
Sheehan Lori
Sheehan Melissa
Sheppard William
Sheridan Martin
Shertel Victoria
Shilpa Kauta
Shimoura Steven
Shin Ju Young
Shinkle Brian
Sidari Jude
Siddiqui Masood
Silversteen Jason
Silverstein Julie
Simpson David
Simpson Robin
Singh Gurmeet
Singh Narinder
Singh Rahul
Singh Reetu
Singh Reshma
Singh Vani
Singson Domingo
Sipala Elizabeth
Sivieri Mark
Skibinski Kathryn
Skinner Kathleen
Slack Melanie
Slobogin Gina
Smail Karen
Smalley Kristina
Smith Bruce
Smith Curtis
Smith Kenneth
Smith Kerri Akaya
Smith Rachel
Smith Renee
Smith Sheri
Smyrna Delaware Sleep Disorder
Snitzer Jack
Snowberger Caroline
Snyder Carrie
Socha Barbara
Sofronski Michael
Soire Ellen
Sokoloff Bruce
Sokoloff Keith
Sollie Lynn
Solomon Lawrence
Soma Parvathi
Somasundaram Parvathi
Somasundarum Parvathi
Sommers William
Sordi Mark
Sorouri Bijan
Sparks Haley
Spiegel Joseph
Sprandio John
Springside Delaware Sleep Disorder
Sprott Candace
Spyropoulos George
Squires Nancy
Stancofski Erik
Stanislav Charles
STankiewicz Edward
Stankiewicz Jason
Steinhardt Joan
Stephens Mary
Stevenson Elaine
Stewart David
Stillabower Michael
Stillman Alfred
Stipo Nicole
Stolar Irena
Stoltz Bradley
Stone Arlen
Stone Tracey
Storlazzi Jordan
Strab Apn Elizabeth
Strang Abigail
Streeter Deborah
Stricklan David
Stuart Kristen
Stumacher Roger
Subbaraya Vidyarani
Sufit Susan
Sullivan Ann Marie
Sullivan Kathy
Sunnergren Kenneth
Sunwoo Bernie Young
Sushereba Elizabeth
Sutter Cynthia
Swanson John
Sweeney Michael
Swift Irene
Sylvester Andrew
Syravanh Chanhsamona
Szeto Irene
Szymaszek Lindsey
Tailor Jayshree
Tan Theodore
Tanchanco Rodrigo Cordero
Tapino Erika Lawson
Tarburton Alyssa
Tatagari Vijayasekhar
Taylor Steven
Tee Andrew
Teitelbaum Jacob
Teixido Michael
Tejeira Ruben
Termini Joseph
Testa Karla
Thomas Jr William
Thomas Michele
Thomas William
Thomas-Gavin Hope
Thompson Caren
Thompson Esther
Thompson Gregory
Tiffany John
Tikhonova Elizaveta
Tikotekar Ashish
Ting Helen
Ting Yvonne
Tinney Julie
Tirlea Carmen
Tjaden Michele
Todaro Raphaele
Tomko Amy
Tonwe Tutse
Toraskar Rakhee
Touchton Ashley
Toussaint Brian
Townsend John
Townsend Suzanne
Townsend-Winter Nancy
Tran Heather
Tranovich LynnMarie
Treisman Glenn Jordan
Tribuiani Melissa
Trivikram Lalitha
Trochimowicz Mark Stephen
Troiano Mark
Tsai Kevin
Tucker Wayne
Tulloch Matthew
Turner Carl
Tyler Melissa
Umosella Charles
Urban Michaelene
Uzelac Giovanna
Valencia Carlo
Valencia Maria Ana
Valentine Kimbery
Varipapa Robert
Varughese Nina
Vasile Anthony
Vasoya Amita
Vaughan Mary Grace
Vegas Anne Marie
Venuti Robert
Verma Nitin
Vermeulen Meagan
Vernose Gerard
Vest Michael
Viganego Federico
Vignola Kimberly
Villamarin Joann
Villar Bryan
Villar Vanessa
Viola Irene
Viterbo George
Volz Emilio
Voss Sandra
Wachter Amy
Wagner Charles
Wainwright Amanda
Wainwright Melissa
Waked Hammoud Tarek
Walbert Tammy
Walia Jasjit
Walker Andrea
Wallace Kristen
Wallace Lisa
Walls Elizabeth
Walsh Brian
Walsh Cassandra
Walter Robert
Walton Anne
Walton Patricia
Wang Carolyn Kie - Lo
Wang Cook Jiadi
Ward Michael
Ware William
Warner Jacqueline
Warren Wilbert
Warrington Alan
Washburn Loriann
Watkins Curt
Weiner Avriham
Weiner Henry
Weinstein Adam
Weiss Alan
Weiss Sandra
Welsh Michael
Werner Megan
Wetherill Stephen
Wexler Sonya
Whalen Thomas
Whealon Spencer
White Mitchell
White Sarah
Why Bradley
Wiggins Brendan
Wilbur Veronica
Willet Andrew
Willey Holly
Willey Kathleen
Williams Moore Jane
Williams Noel
Wilson Adrian
Wilson Robert
Wilson Teshina
Wimmer Neil
Windemuth Brenda
Wingel Deborah
Wingel Mark
Winter Robert
Witherell Colleen
Witt Robert
Wohler Brett
Wolfe Kenneth
Wolfgang Marie
Wollman Judith
Wright Holly
Wydila Michael
Wynn Gail
Xeller Charles
Xellerq Charles
Yacoub Carl
Yadhati Pramod
Yeargan Jon
YERKES PAUL
Yezdani Khaja
Yoder Bonnie
Yonker Preeti
York-Jordan Kathleen
Yost Monique
Youcob Gaber
Young Daniel
Young-Conner Kimberly
Yu Lewis
YUDT KELLY
Zaki Wafik
Zarek Deborah
Zarlengo Raymond
Zarraga Antonio
Zarraga Cynthia
Zdana Cheryl
Zeller Charles
Zeltser Marina
Zhang Jinsong
Zhang YuanYuan
Zhong Xin
Zhu Ying
Ziemer Elleda
Zimmerman Karl
Zimmet Steven
Zoranski Bernard
Zweben Mark
Primary Care Physician (Last Name, First Name)
Enter Primary Care Physician if not found in list above
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11
Diagnosed Conditions/Symptoms
Have you been diagnosed with or treated for any of the following conditions or have the following symptoms?
Night Sweats
Erectile Dysfunction
GERD/reflux
High Blood Pressure
Memory or Cognitive Impairment
Depression
Anxiety or PTSD
Epilepsy or Seizures
Stroke/mini-stroke/TIA
Snoring
Thyroid Disease
Diabetes
Lung Disease (Asthma/COPD)
Sleep Apnea
Morning Headaches
Restless Leg Syndrome
Narcolepsy
Awaken Choking, Gasping
Insomnia
Disrupted Sleep
Periodic Limb Movement Disorder
Difficulty with your hands/dexterity
Excessive Daytime Sleepiness
Heart Disease (CHF, CAD, A-fib, other)
Difficulty understanding, remembering or following instructions
Neuromuscular Disease (MS, ALS, Parkinson’s, etc)
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12
Epworth Sleepiness Scale
*
This field is required.
How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to mark the most appropriate box for each situation. My chance of dozing when...
Never
Slight
Moderate
High
Sitting and reading
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Sitting and talking to someone
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Watching TV
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Sitting quietly after lunch without alcohol
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Sitting inactive in a public place (theater, meeting, etc)
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
In a car, while stopped for a few minutes in traffic
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
As a passenger in a car for an hour without a break
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Lying down to rest in the afternoon when circumstances permit
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Sitting and reading
Sitting and talking to someone
Watching TV
Sitting quietly after lunch without alcohol
Sitting inactive in a public place (theater, meeting, etc)
In a car, while stopped for a few minutes in traffic
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Never
Row 0, Column 0
Slight
Row 0, Column 1
Moderate
Row 0, Column 2
High
Row 0, Column 3
Never
Row 1, Column 0
Slight
Row 1, Column 1
Moderate
Row 1, Column 2
High
Row 1, Column 3
Never
Row 2, Column 0
Slight
Row 2, Column 1
Moderate
Row 2, Column 2
High
Row 2, Column 3
Never
Row 3, Column 0
Slight
Row 3, Column 1
Moderate
Row 3, Column 2
High
Row 3, Column 3
Never
Row 4, Column 0
Slight
Row 4, Column 1
Moderate
Row 4, Column 2
High
Row 4, Column 3
Never
Row 5, Column 0
Slight
Row 5, Column 1
Moderate
Row 5, Column 2
High
Row 5, Column 3
Never
Row 6, Column 0
Slight
Row 6, Column 1
Moderate
Row 6, Column 2
High
Row 6, Column 3
Never
Row 7, Column 0
Slight
Row 7, Column 1
Moderate
Row 7, Column 2
High
Row 7, Column 3
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13
Stop-Bang Sleep Questionnaire
*
This field is required.
No
Yes
Snoring: Do you Snore loudly (louder than talking or loud enough to be heard through closed doors)?
Row 0, Column 0
Row 0, Column 1
Tiredness/fatigue: Do you often feel sleepy during daytime, even after a good night's sleep?
Row 1, Column 0
Row 1, Column 1
Observed Apnea: Have you ever been told you stop breathing during your sleep?
Row 2, Column 0
Row 2, Column 1
Pressure: Do you have or are you being treated for hypertension (high blood pressure)?
Row 3, Column 0
Row 3, Column 1
Body mass index more than 35 kg/m2?
Row 4, Column 0
Row 4, Column 1
Age older than 50 years old?
Row 5, Column 0
Row 5, Column 1
Neck size large (measured around Adam's apple)?
Row 6, Column 0
Row 6, Column 1
Gender (biologic sex) = Male?
Row 7, Column 0
Row 7, Column 1
Snoring: Do you Snore loudly (louder than talking or loud enough to be heard through closed doors)?
Tiredness/fatigue: Do you often feel sleepy during daytime, even after a good night's sleep?
Observed Apnea: Have you ever been told you stop breathing during your sleep?
Pressure: Do you have or are you being treated for hypertension (high blood pressure)?
Body mass index more than 35 kg/m2?
Age older than 50 years old?
Neck size large (measured around Adam's apple)?
Gender (biologic sex) = Male?
No
Row 0, Column 0
Yes
Row 0, Column 1
No
Row 1, Column 0
Yes
Row 1, Column 1
No
Row 2, Column 0
Yes
Row 2, Column 1
No
Row 3, Column 0
Yes
Row 3, Column 1
No
Row 4, Column 0
Yes
Row 4, Column 1
No
Row 5, Column 0
Yes
Row 5, Column 1
No
Row 6, Column 0
Yes
Row 6, Column 1
No
Row 7, Column 0
Yes
Row 7, Column 1
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14
Parasomnia
*
This field is required.
Do you ever or have you ever been told that you do any of the following?
No
Yes
Sleep Walk
Row 0, Column 0
Row 0, Column 1
Talk, yell or scream in your sleep
Row 1, Column 0
Row 1, Column 1
Grind teeth in your sleep
Row 2, Column 0
Row 2, Column 1
Eat when you're asleep
Row 3, Column 0
Row 3, Column 1
Act out dreams when you’re asleep
Row 4, Column 0
Row 4, Column 1
Wet the bed as an adult
Row 5, Column 0
Row 5, Column 1
Wake up confused then fall back asleep
Row 6, Column 0
Row 6, Column 1
Unusual or violent behavior while sleeping
Row 7, Column 0
Row 7, Column 1
Limb or body movements when falling asleep or during sleep
Row 8, Column 0
Row 8, Column 1
Sleep Walk
Talk, yell or scream in your sleep
Grind teeth in your sleep
Eat when you're asleep
Act out dreams when you’re asleep
Wet the bed as an adult
Wake up confused then fall back asleep
Unusual or violent behavior while sleeping
Limb or body movements when falling asleep or during sleep
No
Row 0, Column 0
Yes
Row 0, Column 1
No
Row 1, Column 0
Yes
Row 1, Column 1
No
Row 2, Column 0
Yes
Row 2, Column 1
No
Row 3, Column 0
Yes
Row 3, Column 1
No
Row 4, Column 0
Yes
Row 4, Column 1
No
Row 5, Column 0
Yes
Row 5, Column 1
No
Row 6, Column 0
Yes
Row 6, Column 1
No
Row 7, Column 0
Yes
Row 7, Column 1
No
Row 8, Column 0
Yes
Row 8, Column 1
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15
Insomnia Severity Index
*
This field is required.
Please rate the CURRENT (i.e., LAST TWO WEEKS) SEVERITY of your insomnia problem(s)
Please Select
None
Mild
Moderate
Severe
Very Severe
Please Select
Please Select
None
Mild
Moderate
Severe
Very Severe
Difficulty falling asleep
Please Select
None
Mild
Moderate
Severe
Very Severe
Please Select
Please Select
None
Mild
Moderate
Severe
Very Severe
Difficulty staying asleep
Please Select
None
Mild
Moderate
Severe
Very Severe
Please Select
Please Select
None
Mild
Moderate
Severe
Very Severe
Problem waking up too early
Please Select
Very Satisfied
Satisfied
Neutral
Dissatisfied
Very Dissatisfied
Please Select
Please Select
Very Satisfied
Satisfied
Neutral
Dissatisfied
Very Dissatisfied
How do you feel about your current sleep pattern?
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16
Insomnia Severity Index Continued...
*
This field is required.
Please rate the CURRENT (i.e., LAST TWO WEEKS) SEVERITY of your insomnia problem(s).
Please Select
Not at all Interfering
A Little
Somewhat
Much
Very Much Interfering
Please Select
Please Select
Not at all Interfering
A Little
Somewhat
Much
Very Much Interfering
Interference with your current functioning
Please Select
Not at all Noticeable
A Little
Somewhat
Much
Very Much Noticeable
Please Select
Please Select
Not at all Noticeable
A Little
Somewhat
Much
Very Much Noticeable
Others noticing your sleep problems
Please Select
Not at all Worried
A Little
Somewhat
Much
Very Much Worried
Please Select
Please Select
Not at all Worried
A Little
Somewhat
Much
Very Much Worried
How worried are you about your current sleep problem?
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17
Narcolepsy
*
This field is required.
Do you ever or have you ever been told that you do any of the following?
Yes
No
Felt unable to move (paralyzed) when falling asleep or waking up
Row 0, Column 0
Row 0, Column 1
Suddenly felt weak (in the knees, sagging of jaw/face/head or total body paralysis) during periods of emotion
Row 1, Column 0
Row 1, Column 1
Had vivid or life-like images or hallucinations when falling asleep or waking up
Row 2, Column 0
Row 2, Column 1
Uncomfortable urges to fall asleep during the day
Row 3, Column 0
Row 3, Column 1
Felt unable to move (paralyzed) when falling asleep or waking up
Suddenly felt weak (in the knees, sagging of jaw/face/head or total body paralysis) during periods of emotion
Had vivid or life-like images or hallucinations when falling asleep or waking up
Uncomfortable urges to fall asleep during the day
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
Yes
Row 3, Column 0
No
Row 3, Column 1
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18
Circadian
*
This field is required.
Please answer the following.
Please Select
Yes
No
Please Select
Please Select
Yes
No
Do you generally fall asleep and wake up at the same time?
Please Select
Yes
No
Please Select
Please Select
Yes
No
Do you typically start sleeping between 8 P.M. and 1 A.M?
Please Select
Yes
No
Please Select
Please Select
Yes
No
Do you typically wake up between 5 A.M. and 10 A.M.?
Please Select
Morning
Afternoon
Evening
Night
Please Select
Please Select
Morning
Afternoon
Evening
Night
When do you function best?
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19
Are you allergic to anything?
This can include any type of allergy, food/medicine/substance
YES
NO
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20
Allergies
Please select any allergies you have. If not listed, please enter.
Balsam of Peru
Cat
Cephalosporins
Chromium
Cobalt chloride
Cosmetics
Dilantin
Dimethylaminopropylamine
Dog
Egg
Fish or shellfish
Formaldehyde
Fruit
Fungicide
Garlic
Glyceryl monothioglycolate
Gold (gold sodium thiosulfate)
Hot peppers
House dust mite
Insect sting
Intravenous contrast dye
Latex
Latex
Local anesthetics
Meat
Milk
Mold
Nickel
Non-steroidal anti-inflammatories
Oats
Paraphenylenediamine
Peanut
Penicillin
Perfume
Photographic developers
Pollen
Rice
Semen
Sesame
Soy
Sulfites
Sulfonamides
Tartrazine
Tegretol
Tetracycline
Toluenesulfonamide formaldehyde
Tree nut
Wheat
Balsam of Peru
Cat
Cephalosporins
Chromium
Cobalt chloride
Cosmetics
Dilantin
Dimethylaminopropylamine
Dog
Egg
Fish or shellfish
Formaldehyde
Fruit
Fungicide
Garlic
Glyceryl monothioglycolate
Gold (gold sodium thiosulfate)
Hot peppers
House dust mite
Insect sting
Intravenous contrast dye
Latex
Latex
Local anesthetics
Meat
Milk
Mold
Nickel
Non-steroidal anti-inflammatories
Oats
Paraphenylenediamine
Peanut
Penicillin
Perfume
Photographic developers
Pollen
Rice
Semen
Sesame
Soy
Sulfites
Sulfonamides
Tartrazine
Tegretol
Tetracycline
Toluenesulfonamide formaldehyde
Tree nut
Wheat
Select allergies from list above. If not listed, enter in boxes below
(1) Allergy not listed, enter here
(2) Allergy not listed, enter here
(3) Allergy not listed, enter here
(4) Allergy not listed, enter here
(5) Allergy not listed, enter here
(6) Allergy not listed, enter here
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21
Are you currently taking any medications?
This includes prescription, over the counter, supplements, etc...
YES
NO
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22
Medications
Please select any medications you are taking. If not listed, please enter.
Abilify
Accupril
Aciphex
Actonel
Actos
Adderall
Adipex P
Advair
Advil
Aldactone
Aleve
Altace
Amaryl
Ambien
Amoxil
AndroGel
Apresoline
Aricept
Ativan
Augmentin
Avapro
Avodart
Bactroban
Bentyl
Biaxin
Brilinta
Buspar
Bystolic
Caltrate
Cardizem
Cardura
Catapres
Ceftin
Celebrex
Celexa
Cialis
Cipro
Claritin
Cleocin
Clovate
Cogentin
Concerta
Coreg
Coumadin
Cozaar
Crestor
Cymbalta
Deltasone
Depakote
Desyrel
Detrol
Dexilant
Diabeta
Diflucan
Dilantin
Diovan
Ditropan
Dolophine
Dramamine
Duragesic
Dyazide
Effexor
Elavil
Enbrel
Estrace
Evista
Exelon
Flagyl
Flexeril
Flomax
Flonase
Focalin
Folvite
Fosamax
Gablofen
Glucophage
Glucotrol
HCTZ
Humalog
Humira
Hytrin
Hyzaar
Imitrex
Inderal
Januvia
Keflex
Kenalog
Keppra
Klonopin
K-Tab
Lamictal
Lanoxin
Lantus
Lasix
Latuda
Levaquin
Levemir
Levitra
Lexapro
Lipitor
Lopid
Lopressor
Lotensin
Lovenox
Lunesta
Lyrica
Macrobid
Medrol
Mevacor
Minocin
Mobic
Mycostatin
Namenda
Nasonex
Neurontin
Nexium
NitroStat SL
Nizoral
Norvasc
Novolog
Omnicef
Omnipred
Onglyza
OxyContin
Pamelor
Patanol
Paxil
Pen VK
Pepcid
Percocet
Phenergan
Plavix
Pradaxa
Pravachol
Premarin
Prevacid
Prilosec
Prinivil
Prinizide
Pristiq
ProAir HFA
Procardia
Proscar
Protonix
Prozac
Pyridium
Reglan
Relafen
Remeron
Requip
Restoril
Rheumatrex
Risperdal
Robaxin
Robitussin
Seroquel
Singulair
Soma
Spiriva
Strattera
Suboxone
Symbicort
Synthroid
Tamiflu
Tenormin
Tessalon
Topamax
Travatan
Tricor
Tylenol #2
Uceris
Uloric
Ultram
Valium
Valtrex
Vasotec
Verelan
VESIcare
Viagra
Vicodin
Victoza
Voltaren
Vytorin
Vyvanse
Wellbutrin
Xalatan
Xanax
Xarelto
Xopenex
Zanaflex
Zantac
Zetia
Zithromax
Zocor
Zofran
Zoloft
Zovirax
Zyloprim
Zyprexa
Zyrtec
Abilify
Accupril
Aciphex
Actonel
Actos
Adderall
Adipex P
Advair
Advil
Aldactone
Aleve
Altace
Amaryl
Ambien
Amoxil
AndroGel
Apresoline
Aricept
Ativan
Augmentin
Avapro
Avodart
Bactroban
Bentyl
Biaxin
Brilinta
Buspar
Bystolic
Caltrate
Cardizem
Cardura
Catapres
Ceftin
Celebrex
Celexa
Cialis
Cipro
Claritin
Cleocin
Clovate
Cogentin
Concerta
Coreg
Coumadin
Cozaar
Crestor
Cymbalta
Deltasone
Depakote
Desyrel
Detrol
Dexilant
Diabeta
Diflucan
Dilantin
Diovan
Ditropan
Dolophine
Dramamine
Duragesic
Dyazide
Effexor
Elavil
Enbrel
Estrace
Evista
Exelon
Flagyl
Flexeril
Flomax
Flonase
Focalin
Folvite
Fosamax
Gablofen
Glucophage
Glucotrol
HCTZ
Humalog
Humira
Hytrin
Hyzaar
Imitrex
Inderal
Januvia
Keflex
Kenalog
Keppra
Klonopin
K-Tab
Lamictal
Lanoxin
Lantus
Lasix
Latuda
Levaquin
Levemir
Levitra
Lexapro
Lipitor
Lopid
Lopressor
Lotensin
Lovenox
Lunesta
Lyrica
Macrobid
Medrol
Mevacor
Minocin
Mobic
Mycostatin
Namenda
Nasonex
Neurontin
Nexium
NitroStat SL
Nizoral
Norvasc
Novolog
Omnicef
Omnipred
Onglyza
OxyContin
Pamelor
Patanol
Paxil
Pen VK
Pepcid
Percocet
Phenergan
Plavix
Pradaxa
Pravachol
Premarin
Prevacid
Prilosec
Prinivil
Prinizide
Pristiq
ProAir HFA
Procardia
Proscar
Protonix
Prozac
Pyridium
Reglan
Relafen
Remeron
Requip
Restoril
Rheumatrex
Risperdal
Robaxin
Robitussin
Seroquel
Singulair
Soma
Spiriva
Strattera
Suboxone
Symbicort
Synthroid
Tamiflu
Tenormin
Tessalon
Topamax
Travatan
Tricor
Tylenol #2
Uceris
Uloric
Ultram
Valium
Valtrex
Vasotec
Verelan
VESIcare
Viagra
Vicodin
Victoza
Voltaren
Vytorin
Vyvanse
Wellbutrin
Xalatan
Xanax
Xarelto
Xopenex
Zanaflex
Zantac
Zetia
Zithromax
Zocor
Zofran
Zoloft
Zovirax
Zyloprim
Zyprexa
Zyrtec
Select medication from list above. If not listed, enter in boxes below
(1) Medication not listed, enter here
(2) Medication not listed, enter here
(3) Medication not listed, enter here
(4) Medication not listed, enter here
(5) Medication not listed, enter here
(6) Medication not listed, enter here
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23
Medical Devices/Equipment
Do you use any of these devices? If not listed please specify.
CPAP
Bi-Level PAP
ASV
Nebulizer
APAP
Auto Bi-Level PAP
Oxygen
Other
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24
Medical Equipment
*
This field is required.
If results from this test show that I will need medical equipment in my home...
Please select one for me per my insurance coverage
I will contact DSDC within 48 hours with the name of the company I would like to use. If I do not contact please select one for me per my insurance coverage.
Other
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25
Surgical History
Have you had any of these surgeries?
Bariatric
Uvuloplatophyryngoplasty (UPPP or LAUP)
Inspire Device
Tracheostomy
Rhinoplasty (nose job) or Nose injury
Jaw surgery
Nasal polyps
Pacemaker
Defibrillator
Inspire or Remede
Other implantable devices
Other
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26
Family History
Have your family members been diagnosed with any of the following?
Mother
Father
Sibling
Diabetes
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Heart Disease
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
High Blood Pressure
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Stroke
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Cancer
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Mental Disorder
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Sleep Disorder
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Diabetes
Heart Disease
High Blood Pressure
Stroke
Cancer
Mental Disorder
Sleep Disorder
Mother
Row 0, Column 0
Father
Row 0, Column 1
Sibling
Row 0, Column 2
Mother
Row 1, Column 0
Father
Row 1, Column 1
Sibling
Row 1, Column 2
Mother
Row 2, Column 0
Father
Row 2, Column 1
Sibling
Row 2, Column 2
Mother
Row 3, Column 0
Father
Row 3, Column 1
Sibling
Row 3, Column 2
Mother
Row 4, Column 0
Father
Row 4, Column 1
Sibling
Row 4, Column 2
Mother
Row 5, Column 0
Father
Row 5, Column 1
Sibling
Row 5, Column 2
Mother
Row 6, Column 0
Father
Row 6, Column 1
Sibling
Row 6, Column 2
1
of 7
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27
Family History Continued...
If you selected cancer, mental disorder, or sleep disorder, please specify details below.
What kind of cancer?
What kind of mental disorder?
What kind of sleep disorder?
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28
Do you actively smoke?
*
This field is required.
This includes any use such as cigarettes, e-cigarettes, e-vaporizers, or electronic nicotine delivery systems.
YES
NO
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29
Have you smoked in the past?
This includes any use such as cigarettes, e-cigarettes, e-vaporizers, or electronic nicotine delivery systems.
YES
NO
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30
Smoking consumption per day?
Enter number or fluid ml consumed per day.
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31
Do you consume alcohol?
This includes any type of alcohol.
YES
NO
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32
Enter your alcohol consumption per week
Enter number of drinks
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33
Do you use drugs?
This includes any type of non-prescription/prescription drugs.
YES
NO
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34
Which drugs do you use?
Please select or type if not listed.
Bath Salts
Cannabis
Cocaine
Devil's Breath
Ecstasy
Fentanyl (Abuse)
GHB
Gray Death
Hashish
Heroin
Ketamine
Kratom
Krokodil
LSD
Marijuana
MDMA
Mescaline
Opium
PCP (Phencyclidine)
Psilocybin (Magic Mushrooms)
Quaaludes
Rohypnol
Speed (methamphetamine)
Synthetic Marijuana (Spice or K2)
TCP (Tenocyclidine)
U-47700 (Pink)
Bath Salts
Cannabis
Cocaine
Devil's Breath
Ecstasy
Fentanyl (Abuse)
GHB
Gray Death
Hashish
Heroin
Ketamine
Kratom
Krokodil
LSD
Marijuana
MDMA
Mescaline
Opium
PCP (Phencyclidine)
Psilocybin (Magic Mushrooms)
Quaaludes
Rohypnol
Speed (methamphetamine)
Synthetic Marijuana (Spice or K2)
TCP (Tenocyclidine)
U-47700 (Pink)
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35
Describe your drug usage
Please specify usage amount and intervals
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36
Functional Outcomes of Sleep
Please answer each of the following questions
Yes, Extreme
Yes, Moderate
Yes, a little
No
Do you have extreme difficulty concentrating on things because you are sleepy or tired?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Do you generally have difficulty remembering things because you are sleepy or tired?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Do you have difficulty operating a motor vehicle for short distances (less than 100 miles) because you become sleepy?
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Do you have difficulty operating a motor vehicle for long distances (greater than 100 miles) because you become sleepy?
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Do you have difficulty visiting your family or friends in their home because you become sleepy or tired?
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Has your relationship with family, friends or work colleagues been affected because you are sleepy or tired?
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Do you have difficulty watching a movie or video because you become sleepy or tired?
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Do you have difficulty being as active as you want to be in the evening because you are sleepy or tired?
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Do you have difficulty being as active as you want to be in the morning because you are sleepy or tired?
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Has your mood been affected because you are sleepy or tired?
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Do you have extreme difficulty concentrating on things because you are sleepy or tired?
Do you generally have difficulty remembering things because you are sleepy or tired?
Do you have difficulty operating a motor vehicle for short distances (less than 100 miles) because you become sleepy?
Do you have difficulty operating a motor vehicle for long distances (greater than 100 miles) because you become sleepy?
Do you have difficulty visiting your family or friends in their home because you become sleepy or tired?
Has your relationship with family, friends or work colleagues been affected because you are sleepy or tired?
Do you have difficulty watching a movie or video because you become sleepy or tired?
Do you have difficulty being as active as you want to be in the evening because you are sleepy or tired?
Do you have difficulty being as active as you want to be in the morning because you are sleepy or tired?
Has your mood been affected because you are sleepy or tired?
Yes, Extreme
Row 0, Column 0
Yes, Moderate
Row 0, Column 1
Yes, a little
Row 0, Column 2
No
Row 0, Column 3
Yes, Extreme
Row 1, Column 0
Yes, Moderate
Row 1, Column 1
Yes, a little
Row 1, Column 2
No
Row 1, Column 3
Yes, Extreme
Row 2, Column 0
Yes, Moderate
Row 2, Column 1
Yes, a little
Row 2, Column 2
No
Row 2, Column 3
Yes, Extreme
Row 3, Column 0
Yes, Moderate
Row 3, Column 1
Yes, a little
Row 3, Column 2
No
Row 3, Column 3
Yes, Extreme
Row 4, Column 0
Yes, Moderate
Row 4, Column 1
Yes, a little
Row 4, Column 2
No
Row 4, Column 3
Yes, Extreme
Row 5, Column 0
Yes, Moderate
Row 5, Column 1
Yes, a little
Row 5, Column 2
No
Row 5, Column 3
Yes, Extreme
Row 6, Column 0
Yes, Moderate
Row 6, Column 1
Yes, a little
Row 6, Column 2
No
Row 6, Column 3
Yes, Extreme
Row 7, Column 0
Yes, Moderate
Row 7, Column 1
Yes, a little
Row 7, Column 2
No
Row 7, Column 3
Yes, Extreme
Row 8, Column 0
Yes, Moderate
Row 8, Column 1
Yes, a little
Row 8, Column 2
No
Row 8, Column 3
Yes, Extreme
Row 9, Column 0
Yes, Moderate
Row 9, Column 1
Yes, a little
Row 9, Column 2
No
Row 9, Column 3
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37
Do you fall asleep and wake up at the same time every day?
YES
NO
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38
Do you or have you taken any medications to help you fall asleep?
YES
NO
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39
How many times do you wake up throughout the night?
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40
When you wake up are you able to fall back to sleep quickly?
YES
NO
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41
How many hours of sleep do you average a night?
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42
Do you feel tired during the day?
YES
NO
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43
Do you take naps during the day?
YES
NO
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44
How many cups of caffeinated drinks do you drink during a day?
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45
What do you want to change about your sleeping habits?
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46
Do you have seasonal allergies?
YES
NO
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47
Which treatments are you currently using?
Over the counter medication
Nasal spray
Nasal wash
Allergy shots
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48
Consent for Diagnostic Testing and/or Treatment
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49
Expense Consent
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50
Group Instruction
*
This field is required.
You may be asked to receive instruction regarding the use of equipment or devices from Delaware Sleep Disorder Centers, LLC in a group setting. Most instructions are general in nature regarding basic use and troubleshooting options. Other participants in the group instruction will be present and may hear information that may be protected health information under HIPPA. You have the right not to participate in group instruction by selecting Yes or No.
YES
NO
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51
Date Completed
*
This field is required.
-
Date
Year
Month
Day
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52
Time Completed
*
This field is required.
1
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Minute
AM
PM
PM
AM
PM
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53
Email
example@example.com
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54
Signature & Submission
Please sign your name.
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