FREE SLEEP APNEA RISK ASSESSMENT

Find out now if you could be at risk for sleep apnea when you complete this short survey.

Sleep is a vital part of our daily lives

Yet, 70 million Americans suffer from a sleep disorder and approximately 95 percent of those affected remain undiagnosed and untreated. Sleep deprivation may cause short (or even long-term) health risks (i.e. heart disease, heart attack, stroke, depression and memory loss).

Don’t put yourself at risk another day.

Fill out this quick survey and find out immediately if you should contact one of our Sleep Providers today. You can always email us at sleep@valleysleepcenter.com with questions.

Do you snore?
YesNo

Has anyone noticed that you stop breathing when you're sleeping?
YesNo

During your waking time, do you feel tired, fatigued or not up to par?
YesNo

Have you ever nodded off or fallen asleep while driving a vehicle?
YesNo

Do you have a chance of dozing in these situations:

Sitting and reading?
YesNo

Sitting and talking?
YesNo

Watching television?
YesNo

Sitting inactive in a public place such as a theater or meeting?
YesNo

In a car while stopped in traffic?
YesNo

Do you have high blood pressure?
YesNo

....
ASSESSMENT
If you have answered YES to 2 or more of the questions above, then you are at high risk for a sleep disorder.
If you have answered YES to 1 question, you are at moderate risk of a sleep disorder.
....

Would you like a sleep specialist from Valley Sleep Center to contact you?
YesNo

Best time to call?
MorningAfternoonEvening

Which location do you prefer?

Name of Insurance Provider

Phone number of Insurance Provider

Subscriber ID #

Group Number

First and Last name:

What is your e-mail address:

Best number to reach you during the time you selected above:

Date of birth:

For IE, format is (YYYY-MM-DD)

How did you hear about us? (required)

REQUEST A CONSULTATION

For most insurance plans, you do not need a primary care referral to meet with our board certified sleep physicians.

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