Self Evaluation Step 1 of 4 25% Name* First Last Gender*MaleFemaleDate of Birth* Date Format: MM slash DD slash YYYY Cell PhoneEmail* Weight (in pounds)Height (in inches)Neck Size (in inches)Have you ever been diagnosed with a sleep disorder?*YesNoNight time oxygen use?*YesNoAre you currently using a CPAP Machine?*YesNoDo you use it every night?*YesNo Answer "YES" or "NO" to the following questions:Have you ever been told you stop breathing while asleep?*YesNoHave you ever fallen asleep or nodded off while driving?*YesNoHave you ever woken up suddenly with shortness of breath, gasping or with your heart racing?*YesNoDo you feel excessively sleepy during the day?*YesNoDo you snore or have you ever been told that you snore?*YesNoHave you had weight gain and found it difficult to lose?*YesNoHave you taken medication for, or been diagnosed with high blood pressure?*YesNoDo you kick or jerk your legs while sleeping?*YesNoDo you feel burning, tingling or crawling sensations in your legs when you wake up?*YesNoDo you wake up with headaches during the night or in the morning?*YesNoDo you have trouble falling asleep?*YesNoDo you have trouble staying asleep once you fall asleep?*YesNo ScoreYour Score indicates Severe risk. Please call now to make an appointment for more information. Click Submit to get a copy of your results sent to your email.Your Score indicates High risk. Please call now to make an appointment for more information. Click Submit to get a copy of your results sent to your email.Your Score indicates Moderate risk. Please call now to make an appointment for more information. Click Submit to get a copy of your results sent to your email.Your Score indicates low risk. Please call now to make an appointment for more information. Click Submit to get a copy of your results sent to your email. This iframe contains the logic required to handle Ajax powered Gravity Forms.
