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Take Sleep
Assessment
Reason for your visit
Cleaning
Treatment
Consultation
Emergency
Others
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Reason for your visit
Cleaning
Treatment
Consultation
Emergency
Others
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Have you been told you snore?
Yes
No
Do you have any of these health conditions? (Select All That Apply)
High blood pressure
Diabetes
Shortness of breath
Coronary Artery Disease
None
Do you dream?
Yes, every night
Some nights
No
I’m not sure
Have you ever been diagnosed with Sleep Apnea?
Yes
No
How would you describe your sleep?
Insufficient - Always Tired
Restful
Disruptive
Do you experience any of the following conditions? (Select All That Apply)
Excessive Daytime Sleepiness
Insomnia
Restless Leg Syndrome
Do you work at night?
None of the above
Do you have a CPAP?
Yes
Yes, but I rarely use it
No
How Did You Hear About Desert Sleep and Wellness?
My physician’s office
My hygienist
Google
Email
Referral (Friend or Family)
Social Media
Please provide your information
Preferred Contact Method
Email
Phone
Any further information you’d like to share?
Yes
No
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