Sleep Apnea Assessment Tulsa, OK | Healthy Sleep Tulsa

First Name

Phone

Have you been told you snore?

Yes
No

Do you dream?

Yes, Every Night
No
Not Sure

Do you have any of these health conditions?
(Check all which apply)

High Blood Pressure (90% of persons with HBP also have sleep apnea)
Diabetes (90% of persons with Tyoe 2 Diabetes also have sleep apnea)
Shortness of Breath
Coronary Artery Disease (90% of persons with CAD also have sleep apnea)

Select your desired features for a Sleep Solution
Oral appliances are an option to CPAP.
(Select all answers which apply)

Portable & Travel Friendly
Quiet & Comfortable.
Non-Invasive
Easy to Use & Maintain

Last Name

Gender

Weight

Birthday

Have you ever been diagnosed with Sleep Apnea?

Yes
No

How would you describe your sleep?

Insufficient - Always Tired
Restful
Disruptive

Do you have a CPAP?

Yes, Use Every Night
Yes, Rarely Use
No

How did you hear about our Sleep Services?

My Physician's office
Social Media
Google
Promotional Card
Email
Family or Friend
Health Smiles Tulsa
Healthy Smiles Claremore
Easy to Use & Maintain

Sleep Apnea Assessment – Tulsa, OK

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