First Name
*
Last Name
*
Email
*
Phone
*
Message
What sleep problems seem to be bothering you?
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Snoring
Sleep Apnea
Excessive Sleepiness
Other
Has anyone told you that you snore?
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Yes
No
Do you snore every night or only once in a while?
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Every Night
Once in a while
No
Do you wake up during the night?
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Yes
No
How loud is your snoring? Does it wake up your partner? Can it be heard outside the bedroom?
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Never
Frequently
Occasionally
Has anyone told you that you hold you briefly stop breathing or gasp when you are asleep?
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Yes
No
Do you snort, choke or gasp yourself awake from sleep?
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Yes
No
What daytime symptoms are you experiencing? Check all that apply
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Excessive
Sleepiness
Headache
Sore Throat
Fatigue
Mood Swings
Loss Of Concentration
Other
What routines help improve your snoring?
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What habits affect your routine?
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What sleep position affects your snoring?
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Submit
