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Sleep Health Survey
Sleep Health Survey
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Sleep Health Survey
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https://raphaelsondentalsleepcenter.com/sleep-health-survey
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SLEEP HEALTH SURVEY
Name
Email
Please answer
YES or NO
Snoring - Do you Snore Loudly (loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night)?
Answer: Yes = +1, No = +0
Yes
No
Tired - Do you often feel Tired, Fatigued, or Sleepy during the daytime (such as falling asleep during driving or talking to someone)?
Answer: Yes = +1, No = +0
Yes
No
Observed - Has anyone Observed you Stop Breathing or Choking/Gasping during your sleep?
Answer: Yes = +1, No = +0
Yes
No
Pressure - Do you have or are being treated for High Blood Pressure?
Answer: Yes = +1, No = +0
Yes
No
Bmi - Is your Body Mass Index (BMI) above 35 kg/m2?
Answer: Yes = +1, No = +0
Yes
No
Age - Are you over 50 Years Old?
Answer: Yes = +1, No = +0
Yes
No
Neck - For male, is your shirt collar 17 inches/43 cm or larger? For female, is your shirt collar 16 inches/41 cm or larger?
Answer: Yes = +1, No = +0
Yes
No
Gender - Are you a Male?
Answer: Yes = +1, No = +0
Yes
No
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