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SLEEP DISORDER
ASSESSMENT
Complete the Questionnaire Below
Sleep Apnea is a very serious sleep disorder. Complete the questionnaire below so we can determine if the condition may be impacting your sleep.
1. Have you been told that you snore?
Yes
No
2. Has anyone said that you seem to stop breathing while sleeping?
Yes
No
3. Do you awaken from sleep with chest pain or shortness of breath?
Yes
No
4. Have you ever been diagnosed with sleep apnea?
Yes
No
5. Do you have a CPAP?
Yes
No
6. Do you have diabetes or high blood pressure?
Yes
No
7. Have you ever had a stroke?
Yes
No
8. Have you ever been told that you have a heart disease such as, coronary heart failure, atrial fibrillation, or have had irregular heart rhythms?
Yes
No
Thank you! Your submission has been received!
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