SLEEP APNEA Questionnaire Click Here to complete questionnaire Sleep Apnea Questionnaire Coupon Code Enter Promotional Code if Applicable Name * First Name Last Name Date of Birth * MM DD YYYY Gender * Select Male Female What areas of health are you wanting to improve? * Choose all that apply Performance Muscle Growth Immune Support Mental Performance Weight Loss Weight Gain Energy Gastric protection and repair In your own words tell us what your complaint is * example: "I am tired all the time", or "I feel bloated all the time" Email * Mobile Phone * (###) ### #### Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Height (Feet) * Select 1 2 3 4 5 6 Height (Inches) * Select 1 2 3 4 5 6 7 8 9 10 11 Weight * In pounds Snore? * Do you snore loudly (louder than talking or loud enough to be heard through closed doors)? Yes No Feel Tired? * Do you often feel tired, fatigued, or sleepy during the day? Yes No Stop Breathing? * Has anyone observed you stop breathing during your sleep? Yes No HTN? * Do you have or are you being treated for high blood pressure? Yes No Age over 50? * Are you older than 50 years of age? Yes No Shirt collar * Is your shirt collar 16 inches/40 cm or larger (measured around Adam's apple)? Yes No Male? * Are you male? Yes No How Did You Hear About Us??? * Select Personal Referral (enter name in next question) Office Sign Website Facebook Instagram Youtube Pinterest Twitter Other Social Media IFM Website Other (enter in next question) Enter name of person referring you or other Thank you for completing you questionnaire After clicking submit you will be directed to our facebook page. Please like and invite your friends! We will be reaching out to you within 24 business hours. Thank you! Please like our facebook page and share!
