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Do you already have a prescription for sleep apnea therapy?

  • Yes
  • No

Snoring

Do you snore loudly? (Louder than talking or loud enough to be heard through closed doors)?

  • Yes
  • No

Tired

Do you often feel tired, fatigued, or sleepy during daytime?

  • Yes
  • No

Breathing

Has anyone observed you stop breathing during your sleep?

  • Yes
  • No

Blood Pressure

Do you have or are you being treated for high blood pressure?

  • Yes
  • No

Symptoms

Do you have any of the following symptoms? Select all that apply.

Next

Medical History

Do you have a past medical history of any of the following?
Select all that apply.

Next

Current Medications

Please list any medications that you are now taking. Include non-prescription medications.

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Nasal Obstructions

Do you have a history of nasal obstructions? Or have you ever had nasal polyps removed?

  • Yes
  • No

Facial Surgery

Have you ever had oromaxillofacial surgery?

  • Yes
  • No

What's your name?

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What is your biological sex?

  • Male
  • Female

Demographics

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Email & Phone Number

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