Snoring & Sleep Apnea Consultation
(615) 385-1190
Am I a Candidate?
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Am I a Candidate?
1
Questionnaire
2
Evaluation
Step 1: Risk Assessment Questionnaire
Fill out the 8 “Yes” or “No” questions in the form below then click "Next".
Snoring? Do you Snore Loudly (loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night)?
Yes
No
Tired? Do you often feel Tired, Fatigued, or Sleepy during the daytime (such as falling asleep during driving or talking to someone)?
Yes
No
Observed? Has anyone Observed you Stop Breathing or Choking/Gasping during your sleep?
Yes
No
Pressure? Do you have or are being treated for High Blood Pressure?
Yes
No
Body Mass Index more than 35 kg/m2?
Yes
No
You can skip this question if you do not know!
Age older than 50?
Yes
No
Date of Birth
MM slash DD slash YYYY
Neck size large? (Measured around Adams apple)
Yes
No
For male, is your shirt collar 17 inches / 43cm or larger? For female, is your shirt collar 16 inches / 41cm or larger?
Gender = Male ?
Yes
No
Step 2: One-on-One Evaluation
You're almost there! The next step is a one-on-one evaluation to go over your survey results and complete your Free Screening & Evaluation. Fill out the form below and we'll contact you in a timely manner.
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