Have you been diagnosed with Obstructive Sleep Apnea? *

Have you ever been told you stop breathing while sleeping? *

Do you ever wake up choking or gasping? *

Do you usually wake up tired or unrested? *

Have you ever been told that you snore? *

Do you suffer from migraines/headaches? *

Have you been diagnosed with high blood pressure? *

Do you grind your teeth, clench or have jaw pain? *

Do you find it difficult to breathe through your nose or catch yourself mouth breathing? *

Do you suffer from anxiety or depression? *

Do you experience indigestion or acid reflux? *

When was your last sleep test? *

Are you currently using a CPAP? If no, why not? *

Have you tried an Oral Appliance for treatment? *

Have you been diagnosed with high blood pressure? *

Have you ever fallen asleep or nodded off while driving? *

Do you ever feel excessively sleepy or fatigued during the day? *

Do you suffer from migraines/headaches? *

Do you experience indigestion or acid reflux? *

Do you grind your teeth, clench or have jaw pain? *

Do you suffer from anxiety or depression? *

Full Name *

Phone *

Postal code *

Email *

Age Validation *

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