Sleep Screener

Name

Email Address

Phone Number

Date of Birth

Please answer the following questions by checking if answer YES. Please answer the following questions by checking if answer YES. Do you snore? Do you often feel tired, fatigued, or sleepy during daytime? Has anyone observed that you stop breathing or choke or gasp during your sleep? Do you have or are you being treated for High Blood Pressure? Is your age over 50 years old? Is your neck size larger than 15" (Females) or 16.5" (Males)?

Gender Gender Female Male Prefer not to answer

Your Weight

Your Height