Question 1 of 16

What is your gender?

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Question 2 of 16

How tall are you?

ft. In.
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Question 3 of 16

What year were you born?

Year
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Question 4 of 16

What is your weight?

LBS
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Question 5 of 16

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

Yes No
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Question 6 of 16

Do you sleep less than 7 hours per night?

Yes No
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Question 7 of 16

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

Yes No
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Question 8 of 16

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

Yes No
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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
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Question 10 of 16

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

Yes No
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Question 11 of 16

Do you have difficulty losing weight?

Yes No
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Question 12 of 16

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

Yes No
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Question 13 of 16

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

Yes No
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Question 14 of 16

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

Yes No
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Question 15 of 16

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

Yes No
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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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