Revive Sleep QuizAssess if you are a candidate for our breakthrough treatments! Check any which applies to you * usually wake feeling tired and unrested habitually snore often suffer from waking headaches regularly experience daytime drowsiness or fatigue have blocked nasal passages someone observed you stop breathing during your sleep wake up with mouth feeling dry often wake up choking or gasping aware grind your teeth while sleeping neck circumference greater than 40 cm/ 15.75" Body Mass Index (BMI) more than 35 neck tends to be short and wider posture is suboptimal aware breathing through mouth none applies to me Have you been diagnosed with sleep apnea? * Yes No Do you currently use a CPAP machine? * Yes No N/A Check any which applies to you * large tongue jaw clicks pops or uncomfortable to open wide crooked teeth (or past history before braces) persistent swollen tonsils had dental treatments (fillings, crowns, root canals) had periodontal treatment (deep cleaning or periodontal surgery) had extractions of teeth gag reflex during dental visits childhood headgear none applies to me Check any which applies to you * High blood pressure Gut Issues (Digestive Issues) Mood and Stress disorders Coronary artery disease Stroke Congestive heart failure Heart attack Atrial fibrillation Type 2 diabetes Autoimmune Disease Neurologic Disorders ADHD none applies to me How disruptive are sleep apnea and snoring to your life and daily activities? * Somewhat disruptive Disruptive Very disruptive It affects almost every aspect of my life Not disruptive at all From your perspective, what areas of your life is affected by your sleep apnea? * sleep of self & family work household errands relationships driving self-worth/ value physical well-being emotional well-being academia not affected other: you can talk about this during your consultation How committed are you to fixing your sleep problems once and for all? * Very committed - I want to take care of this ASAP Somewhat committed - Within a few weeks I would like to discuss my options and find out more I do not want to fix my sleep problem This does not apply to me Complete below so we can provide you with a complimentary insurance assessment (no HMO) * PPO Dental No Insurance Name * First Name Last Name Email * Phone * (###) ### #### Date of Birth * If you are under 18yo, please in the last item. MM DD YYYY I am submitting this form for my child. * Please write your name and your relationship to the person with sleep apnea. Your Quiz was submitted. Now you qualify to get your voucher for a Free CPAP Alternative Consultation.