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Find out now if you could be at risk for sleep apnea when you complete this short survey.
Do you snore? (required)
YesNoI don't know
Has anyone noticed that you stop breathing when you're sleeping? (required)
During your waking time, do you feel tired, fatigued or not up to par? (required)
Have you ever nodded off or fallen asleep while driving a vehicle? (required)
Do you have a chance of dozing in these situations:
Sitting and reading? (required)
Sitting and talking? (required)
Watching television? (required)
Sitting inactive in a public place such as a theater or meeting? (required)
In a car while stopped in traffic? (required)
Do you have high blood pressure? (required)
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ASSESSMENT If you have answered YES to 2 or more of the questions above, then you are at high risk for a sleep disorder. If you have answered YES to 1 question, you are at moderate risk of a sleep disorder.
Would you like a sleep specialist from SleepWerx to contact you? (required)
YesNo
Best time to call? (required)
MorningAfternoonEvening
Name of Insurance Provider
Phone number of Insurance Provider
Subscriber ID #
Group number
First and Last name (required)
Your email (required)
Best number to reach you
Date of Birth (required)
How did you hear about us? (required)
GoogleFacebookReferred by my doctorReferred by a friendOther
Please specify if you selected other
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