Achieve Better Sleep, Get Started Today Please Scroll Down to Get Started NAME * First Last Office * Mint Highland Hotel PHONE * E-MAIL * DOB * HEIGHT * WEIGHT * Medical Insurance Blue Cross Blue Shield Cigna United Healthcare Aetna Other MEDICAL INSURANCE ID# Have you had a previous sleep study within 2 years Yes No Please select at least one checkbox.Do you have any of the Following Conditions * High Blood Pressure High Cholesterol GERD/Acid Reflux Stroke Coronary Artery Disease Congestive Heart Failure Irregular Heart Rhythms Heart Attack Any Other Heart Disease Diabetes Obesity Lung Disorders Mood Disorders Depression Anxiety ADD/ADHD Insomnia Narcolespy Clinching/Grinding/Bruxism Please select at least one checkbox.Have you Experienced any of the Following Signs or Symptoms * Someone has told you that you snore Someone has told you that you stop breathing during sleep You awakened gasping for air Restless sleep Non-refreshing sleep Awaking more than 2x per night Short Tempered Daytime sleepiness Difficulty Concentrating Impaired Cognition Fatigue during the day Lack of Energy Morning Dry Mouth Morning Headaches Unintentional Dozing More than 2 (8oz) sources of caffeine daily SNORE Do you Snore loudly (louder than talking or loud enough to be heard through closed doors)? Yes No TIRED Do you often feel Tired, fatigued, or sleepy during daytime? Yes No OBSERVED Has anyone Observed you stop breathing during your sleep? Yes No PRESSURE Do you have or are you being treated for high blood Pressure? Yes No BMI more than 35kg/m2? Yes No AGE over 50 years old? Yes No NECK circumference > 16 inches (40cm)? Yes No GENDER Male? Yes No What is any additional information you would like us to know at this time? SUBMIT
