Sleep Questionnaire

1

Name

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Gender* This field is required.

4

Birth Date* This field is required.

5

Height* This field is required.

Height in inches

6

Weight* This field is required.

Weight in lbs

7

Neck Size (around the Adam's apple)* This field is required.For men, is your neck 17 inches / 43 cm or larger? For women, is your neck 16 inches / 41 cm or larger?

Larger

Smaller

8

Do you have or have you ever been treated for high blood pressure?* This field is required.

YESNO

9

Have you ever been told that you snore?* This field is required.

YESNO

10

Has anyone told you that you stop breathing or choke/gasp during your sleep ?* This field is required.

YESNO

11

Do you often feel tired, fatigued, or sleepy during the daytime?* This field is required.

YESNO