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SLEEP DISORDER
ASSESSMENT
Complete the Questionnaire Below
Sleep Apnea is a very serious sleep disorder. Complete the questionnaire below so we can determine if the condition may be impacting your sleep.
Name
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Phone
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Email
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1. Have you been told that you snore?
Yes
No
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2. Has anyone said that you seem to stop breathing while sleeping?
Yes
No
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3. Do you awaken from sleep with chest pain or shortness of breath?
Yes
No
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4. Have you ever been diagnosed with sleep apnea?
Yes
No
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5. Do you have a CPAP?
Yes
No
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6. Do you have diabetes or high blood pressure?
Yes
No
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7. Have you ever had a stroke?
Yes
No
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8. Have you ever been told that you have heart disease such as, coronary heart failure, atrial fibrillation, or have had irregular heart rhythms?
Yes
No
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Submit Assessment
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