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Man Sleeping

SLEEP ASSESSMENT

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?
2. Has anyone said that you seem to stop breathing while sleeping?
3. Do you awaken from sleep with chest pain or shortness of breath?
4. Have you ever been diagnosed with sleep apnea?
5. Do you have a CPAP?
6. Do you have diabetes or high blood pressure?
7. Have you ever had a stroke?
8. Have you ever been told that you have heart disease such as, coronary heart failure, atrial fibrillation, or have had irregular heart rhythms?

Thanks for submitting!

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