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Adult New Patient Forms
Follow Up Patient Forms
Pediatric Patient Forms (Children 17 and younger)
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Take the Sleep Quiz!
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Adult Patient Forms
or
Pediatric Patient Forms
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First Name
(Required)
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Last Name
(Required)
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Age
(Required)
Please enter a number from
0
to
150
.
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Gender
(Required)
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Email Address
(Required)
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Phone
(Required)
Family and friends tell me I snore loudly!
(Required)
Yes
No
I nod off easily because I feel tired and fatigued throughout the day!
(Required)
Yes
No
I have trouble falling and/or staying asleep during the night!
(Required)
Yes
No
I get sleepy while driving!
(Required)
Yes
No
My leg jerks before I fall to sleep and I sometimes feel like one or both legs have the "creepy crawlies"
(Required)
Yes
No
I have fallen asleep at the wrong time or place like work, movies, church, or parties!
(Required)
Yes
No
I have high blood pressure and/or am overweight!
(Required)
Yes
No
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