Free Sleep Screener

Do you snore? *

Yes

No

Do you often feel tired, fatigued or sleepy during the daytime? *

Yes

No

Has anyone observed that you stop breathing, choke or gasp while you're sleeping? *

Yes

No

Do you have or are you being treated for high blood pressure? *

Yes

No

Is your BMI above 24 (female) or 27 (male)?

Yes

No

Is your age above 50 years old? *

Yes

No

Is your neck size larger than 15" (female) or 16.5" (male)?

Yes

No

Have you ever had a sleep test before? *

Yes

No

Name *

First Name

Last Name

Phone *

(###)

###

####

Preferred Contact Time

Morning

Afternoon