S (snore) Have you been told that you snore? *	Yes No
T (tired) Are you often tired, fatigued, or sleepy during the day? *	Yes No
O (obstruction) Do you stop breathing, choke, or gasp during sleep? *	Yes No
P (pressure) Do you have or are you being treated for high blood pressure? *	Yes No
B (BMI) Is your body mass index greater than 35 ?: *	Yes No
A (age) Are you 50 years old or older?: *	Yes No
N (neck) Do you have a neck circumference greater than 16 inches?: *	Yes No
G (gender) Are you a male?: *	Yes No
First name: *
Last name: *
Address: *
City: *
State: *
Zip Code: *
Email address: *
Phone: *
Referred by:
Date of birth: *
Contact me by phone to review my study results: *	Yes No

Patient Consent

I am the patient and I understand that I am proceeding with a home sleep apnea test as approved by a licensed physician. I understand that untreated sleep apnea is a serious cardiovascular risk factor and it is my responsibility to perform the test within (3) three days. I have been provided with written instructions and can call for additional help with 24-hour availability of qualified personnel to answer any questions to: 888-748-2627.