FOR MORE INFORMATION CALL (888) 844-9845

SLEEP ASSESSMENT

FOR MORE INFORMATION CALL (888) 844-9845

SLEEP ASSESSMENT

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Sleep Assessment

Please Answer the questions below. Your score will automatically be totaled at the bottom of the page.

Phone

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 *

Phone Number *

Email Address *

INSURANCE INFO (on your insurance card)

Birthday

Ins. Policy Number

Provider Phone Number

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North Ogden, UT
1075 North Washington Blvd.
Ogden, UT 84404
(801) 528-4889

Provo, UT
3216 N University Ave.
Provo, UT 84604
(801) 615-2674

American Fork, UT
321 E State Street, St. #1
American Fork, UT 84003
(801) 800-8106

Sandy, UT
8941 South 700 East Suite 204
Sandy, UT 84070
(801) 937-4719

Murray, UT
310 E. 4500 S., Suite 110
Murray, UT 84107
(801) 685-3430

Layton, UT
365 W 1550 N, Suite E
Layton, UT 84041
(801) 528-4912

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About
- Meet Our Dentist
Testimonials
Sleep Apnea
- Myths & Facts
- Treatments
Oral Appliance
Blog
Locations

About
- Meet Our Dentist
Testimonials
Sleep Apnea
- Myths & Facts
- Treatments
Oral Appliance
Blog
Locations

PINTEREST SURVEY

Simply answer the following 5 questions Yes or No to see if you qualify.
If you have any questions or concerns please call: 801-762-6888.

Step 1 of 5

20%

I wake up gasping for air during the night?*

I have been told that I snore?*

I am over the age of 30?*

I feel tired during the day?*

Congratulations!!!
You qualify for a free sleep assessment to try this revolutionary new sleep apnea device. Please provide us your contact info, so we can schedule your free assessment.
Name*
First Last
Phone*
Email
Zip Code*
Please enter your 5 digit zip code

5 QUESTION SURVEY

Simply answer the following 5 questions Yes or No to see if you qualify.
If you have any questions or concerns please call: 801-762-6888.

Step 1 of 5

20%

I wake up gasping for air during the night?*

I have been told that I snore?*

I am over the age of 30?*

I feel tired during the day?*

Congratulations!!!
You qualify for a free sleep assessment to try this revolutionary new sleep apnea device. Please provide us your contact info, so we can schedule your free assessment.
Name*
First Last
Phone*
Email
Zip Code*
Please enter your 5 digit zip code

Provide Your Contact Info for a Free Consultation

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