TAKE YOUR FREE ONLINE SLEEP SCREENING *required fields Step 1 of 5 - Contact Information 20% Personal Info*MaleFemaleDate of Birth*Neck SizeHeightWeightBMI Check any that you experience and list any meds you currently take for each.High Blood Pressure Blood Pressure MedicationsHypothyroidism Hypothyroidism MedicationsCholesterol Cholesterol MedicationsDiabetes Diabetes MedicationsHeart Condition Heart MedicationsAsthma/COPD Asthma/COPD MedicationsAllergies Allergy MedicationsIndigestion Indigestion MedicationsStroke, Heart Attack, CAD or DM Describe, When/Where How likely are you to doze off or fall asleep in the following situationsSitting and ReadingUnlikelyMaybeProbablyDefinitelyWatching TelevisionUnlikelyMaybeProbablyDefinitelySitting Quietly in a Public PlaceUnlikelyMaybeProbablyDefinitelyRiding in a CarUnlikelyMaybeProbablyDefinitelyDriving a CarUnlikelyMaybeProbablyDefinitelyLying Down in the AfternoonUnlikelyMaybeProbablyDefinitelySitting and TalkingUnlikelyMaybeProbablyDefinitelySitting Quietly After LunchUnlikelyMaybeProbablyDefinitelyIn a Stopped CarUnlikelyMaybeProbablyDefinitely Check any that you experience and comment as necessary.Nose Breathing Problem DescribeTrouble Sleeping DescribeSnoring DescribeSleep Apnea DescribePrevious Sleep Study WhenAuto Accident From Sleeping Describe First Name*Last Name*Email* Phone*How Were You Referred to Us?If you were referred to us by a Medical Clinic or Physician, please provide us with their Name, Location, and Phone Number.NameThis field is for validation purposes and should be left unchanged.
