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Questions – Fusion Sleep
Question 1 of 16

What is your gender?

SUBMIT
Question 2 of 16

How tall are you?

ft. In.
BACK SUBMIT
Question 3 of 16

What year were you born?

Year
BACK SUBMIT
Question 4 of 16

What is your weight?

LBS
BACK SUBMIT
Question 5 of 16

Do you tend to feel excessively sleepy or fatigued (listless, no energy) during the day?

Yes No
BACK SUBMIT
Question 6 of 16

Do you sleep less than 7 hours per night?

Yes No
BACK SUBMIT
Question 7 of 16

Do you have a hard time falling asleep or staying asleep?

Yes No
BACK SUBMIT
Question 8 of 16

Do you frequently wake up in the morning with a headache?

Yes No
BACK SUBMIT
Question 9 of 16

Do you have an urge or a restless/uncomfortable feeling in your legs that makes you want to move them in the evening or at night?

Yes No
BACK SUBMIT
Question 10 of 16

Have you been told that you’re restless or move around a lot after falling asleep?

Yes No
BACK SUBMIT
Question 11 of 16

Do you have difficulty losing weight?

Yes No
BACK SUBMIT
Question 12 of 16

Do you frequently wake up during the night to use the bathroom?

Yes No
BACK SUBMIT
Question 13 of 16

Do you know or have you been told that you snore?

Yes No
BACK SUBMIT
Question 14 of 16

Do you sometimes wake up snorting, choking or gasping for air?

Yes No
BACK SUBMIT
Question 15 of 16

Have you been told that you stop breathing in your sleep?

Yes No
BACK SUBMIT
Question 16 of 16

Have you been diagnosed with any of the following:

High blood pressure?

Yes No

Diabetes?

Yes No

Stroke?

Yes No

Heart problems?

Yes No

Sleep disorder?

Yes No

Depression or anxiety?

Yes No
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