Please note: All information must be filled out in order to submit questionnaire.

Personal Information

First Name

Middle

Last Name

Date Of Birth

/ /

Age

Gender

Male Female

Company / Employer

Phone Number

Address

Street Address

City

State

Zip

Height

Feet Inches

Weight

Body Mass Index

Calculation based on height and weight applied to the conventional BMI equation.

Neck Size

Inches

Physician First Name

Physician Last Name

Physician Address

Street Address

City

State

Zip

Medical History

Do you have or have you ever been diagnosed or treated for any of the following conditions?
High Blood Pressure
Heart Disease
Lung Disease
Depression
Diabetes
Stroke
Sleep Apnea
Restless Leg Syndrome or PLMS
Other
Other

Sleep History

Do you have or have you ever been diagnosed or treated for any of the following conditions?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Do you snore?
If yes, is it loud enough to be heard through walls or a door?
Has anyone ever told you that you stop breathing when you are sleeping?
Do you ever wake gasping for breath?
Do you ever wake with your heart racing?
Do you still feel tired after a full night’s sleep?
Do you ever feel tired/sleepy during the day?
Do you fall asleep at inappropriate times? (during a movie, driving)

Do you currently use a CPAP machine? If yes, what pressure?

Additional Comments