Sleep Wellness Center

Fields marked (*) are required.

1. Do you snore loudly? *

   Yes No
2. Do you wake up feeling groggy even after being in bed 8–10 hours? *

   Yes No
3. Are you frequently drowsy during the day? *

   Yes No
4. Have you noticed decreased energy and difficulty concentrating? *

   Yes No
5. Do you ever awaken suddenly at night gasping for breath or with a choking feeling? *

   Yes No
6. Do you suffer from high blood pressure? *

   Yes No
7. Is your neck circumference greater than 15.75 inches? *

   Yes No
8. Do you have a body mass index of more than 35? *

   Yes No
9. First name *
10. Last name *
11. E-mail *
12. Phone (with area code) *