Sleep AssessmentPlease Answer the questions below. Your score will automatically be totaled at the bottom of the page. Name I've been told that I snore * True False I've been told that I stop breathing while I sleep, although I don't remember this when I wake up * True False I have high blood pressure * True False My friends and family say they have noticed changes in my personality * True False I am gaining weight * True False I sweat excessively during the night * True False I get morning headaches * True False I have trouble sleeping when I have a cold * True False I suddenly wake up gasping for breath during the night * True False I am overweight * True False If you scored 30 or higher you show symptoms of Sleep Apnea, a life-threatening disorder that causes you to stop breathing repeatedly – often several hundred times per night – during your sleep. Total: First Name * Last Name * City * State * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Phone Number * Email Address * INSURANCE INFO (on your insurance card) Birthday Ins. Policy Number Provider Phone Number
