First Name

Last Name

Email *

Phone *

This self-assessment will not replace a one-on-one consultation with a qualified healthcare provider. This self-assessment is not intended to diagnose, treat, prevent or cure any healthcare condition.

Please Accept The Terms & Conditions *

I Accept

I Do Not Accept

Your Patient Care Coordinator can help you understand what your assessment responses mean, discuss potential treatment options and answer your questions.

Which of these sleep problems presents the biggest challenge for you right now? Choose only ONE: *

- ADD/ADHD

- Sleep Apnea

- Bedwetting

- Headache / Migraines / Jaw Pain

Let's Consider your sleeping habits. Do you experience any of the following during sleep? Check all that apply: *

Snoring

Gasping

Choking or Coughing

Restless Sleep

Restless Leg Syndrome

Insomnia

None

During the day, do you experience any of the following? Check all that apply: *

Waking Feeling Tired

Morning Headaches

Brain Fog

Confusion Upon Waking

Daytime Fatigue

Difficulty Concentrating

Anxiety and/or Stress

Feeling Overwhelmed

Memory Problems

Unexplained Weight Gain

Sneezing/Runny Nose

Itchy Eyes or Nose

Cough

Shortness of Breath

Tooth Sensitivity

Jaw Joint and/or Face Pain

Worn/Broken Teeth

None

Do You Have A History Of Any Of The Following Conditions? (Check All That Apply)

Heart Palpitations

GERD/Acid Reflux/Heartburn

Nasal Congestion

Chronic Allergies

Hypertension/High Blood Pressure

Depressed Mood/Irritability

Cancer

Mouth Breathing

Hypothyroidism

Fibromyalgia

Chronic Pain

None

Do you currently take medications for any of the following? Check all that apply:

Hypertension

Depression

Anxiety

Gastric Reflux

Heart Disease

ADHD

Chronic Pain

None

Let's talk about your oral health. Select all that apply:

I have had my wisdom teeth extracted

I have had other adult teeth extracted

I wore braces to straighten teeth

I probably should have worn braces

I have had my tonsils removed

I have had my adenoids removed

None

Has anyone ever told you that you stop breathing while you are sleeping?

Yes

Have you ever taken a home sleep study? *

Yes

Have you been diagnosed by a physician with mild-to-moderate obstructive sleep apnea or sleep disordered breathing?

- Yes

- No

Has a doctor ever prescribed the use of a CPAP machine? *

Yes

Tell us in your words

How have these problems affected your life, and what would you like to see changed?