Sleep Apnea Quiz Sleep Disorder Quiz Patient's First Name Patient's Last Name Cell Phone Email YesNo1. Have you been told you snore? YesNo2. Does your family have a history of premature death? YesNoDo you have diabetes? YesNoHave you ever been told you have coronary artery disease? YesNoDo you have high blood pressure? YesNo6. Have you ever experienced irregular heart rhythms? YesNo7. Have you ever been diagnosed with sleep apnea? YesNo8. Do you dream? YesNo9. Do you awaken from sleep with chest pain or shortness of breath? YesNo10. Has anyone said that you seem to stop breathing while sleeping? YesNo11.Have you ever had a stroke? YesNo12. Have you ever been told you have congestive heart failure? YesNo13. Do you have or did you ever have atrial fibrillation? YesNo14. Are you currently taking pain meds? YesNo15. Do you have a CPAP? YesNo16. Do you use a CPAP at least 4 hours every night? Show did you hear about us? Select One Radio Social Media Family/Friend Email Promotional Card/Flyer Google/Other Search Submit Your request has been sent -- we will be in contact with you shortly. There was an error! Please phone our office.