Name *

Phone *

Email *

1. Snore - Do you snore loudly? (Louder than talking or loud enough to be heard through closed doors)
NoYes

2. Tired - Do you often feel tired, fatigued, or sleepy during the daytime?
NoYes

3. Observed - Has anyone observed you stop breathing during sleep?
NoYes

4. Pressure - Do you have (or are you being treated for) high blood pressure?
NoYes

5. Body Mass Index (BMI) – visit HERE to find yours:
Less than 35More than 35

6. Age – Are you older than 50 years old?
NoYes

7. Neck Size – Is your shirt collar 16 inches / 40cm or larger?
NoYes

8. Gender – Are you male?