Assessment

Please Answer the questions below.

Your score will automatically be totaled at the bottom of the page. 

I've been told that I snore
I've been told that I stop breathing while I sleep, although I don't remember this when I wake up
I have high blood pressure
My friends and family say they have noticed changes in my personality
I am gaining weight
I sweat excessively during the night
I get morning headaches
I have trouble sleeping when I have a cold
I suddenly wake up gasping for breath during the night
I am overweight
If you scored 30 or higher you show symptoms of Sleep Apnea, a life-threatening disorder that causes you to stop breathing repeatedly – often several hundred times per night – during your sleep.

Total:

 

 

Name:
Phone:
Email:
INSURANCE INFO (on your insurance card)
Birthday
Ins. Policy Number
Provider Phone Number