Providing Exceptional Sleep Services For Over 25 Years

Answer the following questions:

Name:
Email:
1.) Do you snore loudly (loud enough to be heard through closed doors)?
Yes     No
2.) Do you often feel tired, fatigued or sleepy during the daytime?
Yes     No
3.) Has anyone abserved you stop breathing during your sleep?
Yes     No
4.) Do you have or are you being treated for high blood pressure?
Yes     No
5.) Male gender?
Yes     No
6.) Age 50 or older?
Yes     No
7.) Body Mass Index (BMI) greater than 35? (See below for assistance.)
Yes     No
8.) Neck circumference greater than 16 inches?
Yes     No

BMI is > 35 if weight is greater
than listed for corresponding height.
Height (in)
59”
60”
61”
62”
63”
64”
65”
66”
67”		 Weight (lb)
173
179
185
191
197
204
210
216
223
Height (in)
68”
69”
70”
71”
72”
73”
74”
75”
76”		 Weight (lb)
230
237
243
250
258
265
273
279
287
(515) 226-0900 (Iowa)   |   (605) 362-6201 (South Dakota)   |   [email protected]